Date Published: January 25, 2011
Publisher: Public Library of Science
Abstract: The Malaria Eradication (malERA) Consultative Group on Cross-Cutting Issues draw out common themes identified by different discussion groups that must be addressed to prepare for malaria eradication.
Partial Text: During their deliberations, scientists in the various Consultative Groups contributing to the Malaria Eradication Research Agenda (malERA) concentrated on research questions relevant to their thematic areas. But, in addition, they also briefly noted many issues of relevance beyond their own domains. Some of these issues are likely to be critically important in malaria elimination/eradication programs. Consequently, they received special attention from the malERA Consultative Group on Integration Strategies. In this paper, we focus on the research and development needs of these important cross-cutting issues, especially in the context of historical reports of reasons for the failure of past campaigns. Consideration of these cross-cutting issues, we argue, is essential for regional elimination and, ultimately, global eradication of malaria, but is also relevant for scaled-up and improved control of disease.
The Consultative Group identified many cross-cutting topics of special significance by examining reports of the failures and successes of earlier approaches to regional elimination of malaria. History reveals that political, social and human factors are likely to be just as important as, if not more important than, biological and technological factors, and that a multidisciplinary approach to elimination/eradication is essential. Accordingly, special attention was given during the malERA consultations to finding synergies and strategies to prevent the “silo effects” that can occur when specialist groups work in isolation. It is important to identify critical partnerships between malaria elimination/eradication programs and programs in health or education, such as integrated management of childhood illness. Similarly, it is important to recognise the need to address social determinants of health for successful malaria eradication campaigns. Finally, ongoing critical analysis of the success or failure of current elimination efforts constitutes a research agenda in its own right, as exemplified in numerous campaigns against other diseases ,.
The Global Malaria Action Plan (GMAP)  is focused predominantly on control, but nevertheless includes eradication as an ultimate goal. The malERA process, with its paradigm shift from control to elimination, has produced significant additions to GMAP by defining a research agenda that will assist in interruption of transmission. The malERA process emphasises the importance of clearly defining the essential research and development needed to achieve specific goals. That is, it focuses on the minimal essentials—what we “need to know”—rather than what would be maximally possible to know or even “nice to know.”
The GMAP has identified the need to continue and scale up control of malaria in highly endemic areas for maximal reduction of morbidity and mortality, and recognises this as a priority for the foreseeable future . As the malaria map shrinks and malaria incidence falls, some countries may consider attacking remaining foci with an elimination agenda. Many pre-elimination considerations are related directly to the competence and readiness of the health system, and are discussed in the malERA paper on health systems and operational research . Decision-makers must also balance the consequences of diverting resources from urgent clinical needs to a problem that by definition is causing little morbidity.
Cross-cutting research is needed to make the case for long-term investment in eradication for the global public good and to ensure that financial support is available for the “last mile” before elimination . This case should align with, and complement, important and related development themes such as global security, migration, food security, and climate change. If research findings suggest that the case is strong, malaria eradication could be included in global policies for health that follow on from the Millennium Development Goals beyond 2015 . Importantly, a development agenda consistent with the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action , should be accompanied by strong harmonization with the GMAP and the goals of the Roll Back Malaria Partnership .
Malaria elimination has a very different endpoint from malaria control and this change of paradigm demands the development of specific measures of progress. New infections are a direct measure of ongoing transmission but require labor-intensive, active surveillance studies, particularly during the elimination phase in regions previously experiencing high transmission where immune individuals are unlikely to experience symptomatic disease. After some years, as immunity declines, infection is more likely to be symptomatic and may then be a good surrogate marker for the detection of continued or resumed transmission during surveillance. Thus, at the end of the process, some years after elimination has been achieved and the population has lost clinical immunity, surveillance of clinical cases can become a guide to transmission. However, there are many years between the time when transmission can be measured in endemic areas (albeit with difficulty and high cost) and the time when active surveillance of occasional cases becomes a useful measure (see also ,).
Many past efforts at malaria elimination have failed because the health system failed during the implementation of stand-alone programs . This failure, through neglect or at least under-resourcing during implementation of vertical programs, resulted in the pessimistic view that malaria can only be eliminated in regions where economic progress and stable governance are in place that support well-functioning health systems. Even if a region initially opts for a purely vertical approach, when transmission declines, patient needs for appropriate diagnosis and treatment in the general health system become part of the surveillance system and need to be integrated with existing health system structures for local responses and central monitoring ,. Moreover, diagnosis and appropriate treatment can contribute to reduction in transmission, and good health facilities are essential for management of other febrile illnesses. For these reasons, a malaria elimination program simply cannot succeed in the absence of an effective health system.
All of the consultative groups recognized the need for training and capacity building in the context of elimination, from discovery research in the laboratory, through social sciences research in communities, and on to operational research in the context of health systems thinking. Master’s level research training that introduces the principles of a scientific approach, epidemiology, and evidence-based decision making would benefit anyone involved in deciding about resource allocation, timing, and refinement of the elimination approach before, during, and after any elimination/eradication program. Training for the eradication research agenda also needs to be accompanied by training of public health leaders and managers with substantial knowledge of malaria.
All the consultative groups acknowledged the importance of strong information systems that are reliable and responsive to local needs for rapid intervention, and that provide inputs to national and regional databases. The requirements for information systems will change over time with changes in transmission but an important attribute of these systems should be harmonization and the avoidance of unnecessary duplication to meet, for example, special or frequent requests from funding agencies. Importantly, additional sources of information have to be integrated into existing information systems to allow modeling of future interventions, to facilitate the analysis of system-wide effects for costing and implementation, and to provide a resource for researchers who are modeling transmission, as discussed in other malERA articles (also see ,).
Successful public health programs are characterized by community engagement and good communication, but how to achieve these critical success factors is not well understood. Community case management and treatments such as piloted in Tigray , can be effective, but support from all sectors of society is critical, particularly where there is a requirement for behavioural change. Strategies are required to explain why efforts against malaria need to be maintained, even when malaria cases are extremely rare. Conversely, governments also have to choose the correct time, and explain the rationale for stopping certain interventions. We need to understand how public perception affects such decisions and provide guidance for countries on when certain interventions will no longer be cost-effective, and we have to communicate this information effectively.
An important part of the malERA process was to identify cross-cutting issues that could facilitate the achievement of the goal of elimination, particularly in the light of past failures, and build on the GMAP that already includes eradication as a long-term goal. As recognized by the whole malaria community, integration is a prerequisite for success.