In viaggio con la malaria

1. In viaggio con la malaria SeminarioL'avetefatto a me Milano, 22 marzo 2014 Franco Pagnoni pagnonif@who.int

2. www.who.int/malaria

3. Approximately 3.3 billion at risk of malaria and 1.2 billion at high risk Popolazioni a rischio malarico Total population Population at any risk Population at high risk High risk (%) 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%

4. Il mondo ridisegnato dalla malaria Dorling D Worldmapper. PLoS Med 4 (1), 2007

5. Risorse per lottaalla malariaAfrica sub-sahariana, 2005-2012

6. Le zanzariere impregnate di insetticida a lunga durata d'azione Riduzione del 25% della mortalità per chi dorme stabilmente sotto zanzariera impregnata

7. Prevenzione – Disponibilità di zanzariere impregnate di insetticida a lunga durata d'azioneAfrica – 2004-2013

9. Prevenzione – Popolazione protetta da zanzariere o spray intradomiciliare – Africa

10. Prevenzione – Protezione della donna in gravidanza Africa Gravità ingravescente: 1° gravidanza > 2° gravidanza > gravidanze successive Insuffcienza renale acuta Edema polmonare

11. Prevenzione – Protezione della donna in gravidanza Africa

12. Diagnosi di malaria

13. Diagnosi di malaria

14. Incidenza e mortalità

15. Incidenza e mortalità

16. Il vaccinoantimalaricio - ilciclo del Plasmodio 16

17. I punti di azione dei diversi vaccini antimalarici Prevent infection Reduce clinical disease severity Interrupt transmission Target stage Clinical effect PRE-ERYTHROCYTIC (RTS,S) BLOOD STAGE SEXUAL STAGE

18. Pre-erythrocytic Vaccines MSP1 AMA1 MSP3 GLURP, SERA, SR11.1, P27, MSP2, EBA175, PvDBP, Rh Antibodies Pvs25 /Pfs25 AgAPN1 Pfs230 Pfs48/45 <50 Pf Pv CSP TRAP LSA1 LSA3 CELTOS <5 Antibodies Effector T cells ~100,000,000,000 Antibodies

19. Many Blood stage vaccines are under evaluation MSP1 AMA1 MSP3 GLURP, SERA, SR11.1, P27, MSP2, EBA175, PvDBP, Rh Antibodies Pvs25 /Pfs25 AgAPN1 Pfs230 Pfs48/45 <50 Pf Pv CSP TRAP LSA1 LSA3 CELTOS <5 Antibodies Effector T cells ~100,000,000,000 Antibodies

20. Sexual stage/mosquito antigen vaccines are conceptually attractive for interrupting transmission MSP1 AMA1 MSP3 GLURP, SERA, SR11.1, P27, MSP2, EBA175, PvDBP, Rh Antibodies Pvs25 /Pfs25 AgAPN1 Pfs230 Pfs48/45 <50 Pf Pv CSP TRAP LSA1 LSA3 CELTOS <5 Antibodies Effector T cells ~100,000,000,000 Antibodies

21. 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! Take home messages

22. In viaggio... senza la malaria

23. In viaggio... senza la malaria http://www.who.int/ith/en/ http://www.who.int/topics/malaria/en/ http://www.iamat.org/disease_details.cfm?id=140&gclid=CPSIxtPPmb0CFWfLtAod1AsAIg

24. Interventi di lotta alla malaria a base comunitaria ------------The Rapid Access Expansion 2015 project

25. Razionale Impact facility-based interventions alone fail to impact on child mortality Equity iCCM example of a strategy to achieve equitable results HF services are less likely to be accessed by the poor Opportunity costs > direct costs

26. New findings on disparities 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.' 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

27. 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 • C'è una notevole sovrapposizione sintomatologica tra malaria e polmonite • I test diagnostici (RDT), se negativi, consentono di escludere la malaria

28. RAcE 2015 - Key elements Award Objectives Increase access to correct diagnosis, treatment and referrals for malaria, pneumonia and diarrhea at the community level Stimulate policy review and regulatory update on disease case management at the community level (WHO comparative advantage) • 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)

29. Malawi: 4 districts, 190,359 children; Consortium of 4 NGOs led by SAVE; start April 2013 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 Consortium Abia state: 6 LGAs, 245,000 children: Society for Family Health November 2013 Mozambique: 4 provinces, 308,000 children; SAVE+MC; April2013

30. Total coverage: 1,286,000 children aged 2-59 months living in "hard to reach" areas, each year, in 5 countries

31. Grazie per l'attenzione