11

In viaggio con la malaria

Franco Pagnonipagnonif@who.int

Seminario L'avete fatto a meMilano, 22 marzo 2014

22

www.who.int/malaria

33

Popolazioni a rischio malarico

Approximately 3.3 billion at risk of malaria and 1.2 billion at high risk

Total population

Africa 774 647 586 76%Americas 895 137 61 7%

Eastern Mediterranean 540 295 66 12%Europe 887 22 2 0%South-East Asia 1,721 1,319 457 27%Western Pacific 1,763 888 54 3%

World 6,581

3,308

1,226

19%

Population at any risk

Population at high risk

High risk (%)

44

Il mondo ridisegnato dalla malaria

Dorling D Worldmapper. PLoS Med 4 (1), 2007

55

Risorse per lotta alla malariaAfrica sub-sahariana, 2005-2012

66

Le zanzariere impregnate di insetticida a lunga durata d'azione

Riduzione del 25% della mortalità per chi dorme stabilmente sotto zanzariera impregnata

77

Prevenzione – Disponibilità di zanzariere impregnate di insetticida a lunga durata d'azione

Africa – 2004-2013

88

99

Prevenzione – Popolazione protetta da zanzariere o spray intradomiciliare – Africa

1010

Prevenzione – Protezione della donna in gravidanza Africa

Gravità ingravescente: 1° gravidanza > 2° gravidanza > gravidanze successiveInsuffcienza renale acutaEdema polmonare

1111

Prevenzione – Protezione della donna in gravidanza Africa

1212

Diagnosi di malaria

1313

Diagnosi di malaria

1414

Incidenza e mortalità

1515

Incidenza e mortalità

1616 16

Il vaccino antimalaricio - il ciclo del Plasmodio

1717

Prevent infection

Reduce clinical diseaseseverity

Interrupttransmission

Target stage Clinical effect

PRE-ERYTHROCYTIC(RTS,S)

BLOOD STAGE

SEXUAL STAGE

I punti di azione dei diversi vaccini antimalarici

1818 18

Pre-erythrocytic Vaccines

<50

~100,000,000,000

<5

Antibodies

Antibodies

Effector T cells

Antibodies

Pf Pv CSPTRAPLSA1 LSA3

CELTOS

MSP1AMA1MSP3

GLURP, SERA, SR11.1, P27, MSP2, EBA175, PvDBP, Rh

Pvs25/Pfs25

AgAPN1Pfs230

Pfs48/45

191919

Many Blood stage vaccines are under evaluation

<50

~100,000,000,000

<5

Antibodies

Antibodies

Effector T cells

Antibodies

Pf Pv CSPTRAPLSA1 LSA3

CELTOS

MSP1AMA1MSP3

GLURP, SERA, SR11.1, P27, MSP2, EBA175, PvDBP, Rh

Pvs25/Pfs25

AgAPN1Pfs230

Pfs48/45

202020

Sexual stage/mosquito antigen vaccines are conceptually attractive for interrupting transmission

<50

~100,000,000,000

<5

Antibodies

Antibodies

Effector T cells

Antibodies

Pf Pv CSPTRAPLSA1 LSA3

CELTOS

MSP1AMA1MSP3

GLURP, SERA, SR11.1, P27, MSP2, EBA175, PvDBP, Rh

Pvs25/Pfs25

AgAPN1Pfs230

Pfs48/45

2121

Take home messages

There is no licensed or available malaria vaccine One candidate RTS,S/AS01 is the most advanced, and the first

WHO recommendations on use are expected in 2015 Even higher efficacy vaccines are desired and we have 2030 goals

for highly effective clinical disease prevention and elimination vaccines

Non-vaccine control ↓deaths by 25% to estimated 660,000 over last decade. Emerging drug and insecticide resistance threaten malaria control. New tools are needed.

Malaria Vaccine R&D is a very active and exciting area!

2222

In viaggio... senza la malaria

2323

In viaggio... senza la malaria

http://www.iamat.org/disease_details.cfm?id=140&gclid=CPSIxtPPmb0CFWfLtAod1AsAIg

http://www.who.int/ith/en/

http://www.who.int/topics/malaria/en/

2424

Interventi di lotta alla malaria a base comunitaria

------------The Rapid Access Expansion 2015 project

2525

Razionale

Impacto facility-based interventions

alone fail to impact on child mortality

Equityo iCCM example of a strategy

to achieve equitable results o HF services are less likely

to be accessed by the pooro Opportunity costs > direct

costs

2626

New findings on disparities

Many regions have reduced disparities in under-five mortality between the poorest and the richest except Sub-Saharan Africa and South Asia

Under-five mortality rate has declined among even the poorest in all regions Source: UNICEF analysis based on Pedersen, J., et al., Levels and Trends in

Inequity and Child Mortality: Evidence from DHS and MICS surveys', working paper, unpublished, 2013.'

2727

C'è una notevole sovrapposizione sintomatologica tra malaria e polmonite

I test diagnostici (RDT), se negativi, consentono di escludere la malaria

Malaria, polmonite e diarrea sono le cause più frequenti di mortalità post-neonatale

UN Child Mortality Report 2010

Razionale per un approccio integrato a malaria, polmonite e diarrea

2828

RAcE 2015 - Key elements

Award

Grant awarded by CIDA in April 2012, CAD 74.5 million

5 year program in 5 countries: Malawi, Mozambique, DRC, Niger, Nigeria (2 states)

Selection criteria: high disease burden, enabling policy, commitment by MoH, potential for scale-up;

Implemented through NGOs; 2M/country/yr – 3 M/yr in NIgeria (1.5M/state)

Objectives

1. Increase access to correct diagnosis, treatment and referrals for malaria, pneumonia and diarrhea at the community level

2. Stimulate policy review and regulatory update on disease case management at the community level (WHO comparative advantage)

2929

Malawi: 4 districts, 190,359 children; Consortium of 4 NGOs led by SAVE; start April 2013

Mozambique: 4 provinces, 308,000 children; SAVE+MC; April2013

DRC: 7 Health Zones in Tanganika district, 150,000 children; IRC; September 2013

Niger: 4 districts, 230,833 children; World Vision; July 2013

Nigeria: Niger state, 6 LGAs, 162,000 children; Malaria ConsortiumAbia state: 6 LGAs, 245,000 children: Society for Family HealthNovember 2013

3030

Total coverage: 1,286,000 children aged 2-59 months living in

"hard to reach" areas, each year, in 5 countries

3131

Grazie per l'attenzione