“It takes vision from
our leaders to project
themselves into the
future and determine
what resources are
required to keep the
- Dr Jimmie Rodgers
Today's Session Summaries.
We couldn’t possibly fit them all in, so here are just ten of the latest highlights from the Congress…
The second full day began with a plenary covering malaria in a global health context. Prof Barbara McPake (U. of Melbourne) reminded us how much the world – and global health – have changed in a lifetime. In many ways, the shifts are reflected in the sustainable development goals framework, and in particular the need to address health in a holistic and integrated way. Malaria, she argued, is both cause and effect of poverty and successful investments in malaria control have been shown to contribute to poverty reduction.
Ambassador Hideo Suzuki (Japan Ministry of Foreign Affairs) provided an overview of Japanese strategies and priorities in global health, including their plans for hosting of the G20 summit in Osaka in 2019. “Without healthy people we cannot expect economic growth and development or justice,” he suggested. In relation to malaria, he noted challenges that call for immediate action – including multidrug resistance in the Greater Mekong subregion, and insecticide resistance In Africa. Ambassador Suzuki highlighted the importance of linking vertical programmes for malaria and the achievement of universal health coverage.
The focus of the following panel discussion – and much of the day – was partnerships. We heard about alliances with the highest levels of government – as embodied by the Asia Pacific Leaders Malaria Alliance (APLMA) – and the importance of establishing platforms for collaboration that spans strategic and governmental areas, the private sector and operational levels. Two very different models highlighted among many other examples was the partnership approach of Unitaid, and the enduring international Rotary movement, which has mobilized over US$2bn for global health efforts.
Effective partnership featured as one of the central messages of the Global Civil Society for Malaria Elimination (CS4ME) Declaration that was published at the end of the day on Tuesday.
The partnering theme was also picked up in a session on ‘Innovation and partnering for tool development in the malaria elimination era’. Collaboration, the presenters argued, is essential to responding dynamically to the malaria situation on the ground: to data, for example, where the flexibility of community, NGOs and governments can allow adaptation to the current situation or context. Examples cited included a public–private–academia platform in Japan, joint and flexible approaches to meeting the needs of mobile and migrant populations, and supporting integrated approaches to fever management.
Several sessions have begun to unpack the complex issues surrounding residual malaria transmission and mass drug administration. Common experiences from East and West Africa, Vietnam, Papua New Guinea and Solomon Islands all highlighted that bed net/insecticide spraying have contributed significantly to malaria reduction, but even with high uptake some transmission persists. Contributing factors are thought to include insecticide resistance, outdoor and early evening biting, human behaviour and inconsistent use of bed nets.
We also heard about mass drug administration (MDA) trials in Myanmar, Vietnam, Cambodia and Laos. MDA treats asymptomatic and undetectable malaria as well as clinical cases – which is important because molecular tests suggest much higher persistent malaria than rapid diagnostic tests have previously shown. In these trials MDAs were well tolerate and safe. MDA showed rapid reductions in malaria but some rebound when MDA was halted. Low migration and geographic isolation we associated with good MDA outcomes, and there was no evidence of resistance selection. Community engagement and trust were seen as a critical element of MDA implementation.
And while vector control may be one of the simplest and most cost-effective methods we have for holding back malaria, we heard it is challenged by insecticide resistance, sometimes ineffectual delivery, limited access, changing landscapes, vector ecology and sustainability. Prof Janet Hemingway (Liverpool School of Tropical Medicine) described the current insecticide situation very clearly when she warned “we cannot pretend that the current tools are working as they were 10–15 years ago – they’re not.” Pyrethroids are widely used for bed net treatment, and yet they are no longer working well in much of Africa. We also heard that vector control and vector surveillance must go increasingly hand-in-hand.
In several sessions, panellists argued that a specific focus is needed to create markets for new products and accelerating access to these products, and removing barriers to early adoption. We heard later that a new regional platform had been launched at the Congress to do just that: The Vector Control Platform for Asia Pacific (VCAP) links diverse sectors and aims to stimulate the insecticide market and drive regional malaria elimination by 2030. Partnerships once again.
Pregnant women are more susceptible to malaria, with an estimated 125 million women at risk of malaria in pregnancy (MiP) every year, with associated adverse maternal and pregnancy outcomes. Focused presentations showed that coverage varies for antenatal care and intermittent preventive treatment in pregnancy (IPTp) across countries and also identified missed opportunities for IPTp, such as women attending ANC. Among the recommendations for improving outcomes for women and children were strengthening the coherence of policies across malaria and reproductive health and alleviating supply chain bottlenecks.
Finally, we should be drawing more now on experiences with the polio fight, including the importance of planning for the malaria elimination endgame in advance, as well learning and adapting strategies as we go. Among those lessons are the importance of working together (clearly a recurring theme today) and multisectoral engagement, including civil society. Philip Welkhoff (Gates Foundation) argued that disease surveillance, mapping and targeted interventions using existing infrastructure are key, and that gradually intensifying a one-size-fits-all strategy wastes time and resources. Rather, mapping populations and heterogeneity of malaria transmission, and tailoring an appropriate mix of sub-nationally targeted interventions is more likely to yield results.