11 In viaggio con la malaria Franco Pagnoni Seminario L'avete fatto a me Milano, 22 marzo 2014

22

33 Popolazioni a rischio malarico Approximately 3.3 billion at risk of malaria and 1.2 billion at high risk Total populatio n Africa % Americas % Eastern Mediterranean % Europe % South-East Asia1,721 1, % Western Pacific1, % World6,581 3,308 1,226 19% Populatio n 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 malaria Africa sub-sahariana,

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 –

88

99 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 vaccino antimalaricio - il ciclo del Plasmodio

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

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

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

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

21 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!

22 In viaggio... senza la malaria

23 In viaggio... senza la malaria 0&gclid=CPSIxtPPmb0CFWfLtAod1AsAIg

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

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

26 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.'

27 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

28 RAcE 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)

29 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 Consortium Abia state: 6 LGAs, 245,000 children: Society for Family Health November 2013

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