CHINESE MALARIAL RESEARCH IN MADAGASCAR AND

UNCLAS ANTANANARIVO 000142


STATE FOR AF/EPS AND AF/E - MBEYZEROV

E.O. 12958: N/A
TAGS: SOCI TBIO EAID CN MA
SUBJECT: CHINESE MALARIAL RESEARCH IN MADAGASCAR AND
COMOROS

REF: 08 ANTANANARIVO 0628


1. (U) Summary: Chinese researchers have targeted several
small islands: Nosy Be, Madagascar and Moheli, Comoros, to
conduct drug trials of a new treatment with the hopes of
eradicating malaria. Because malaria is among the top three
causes of death and disease, especially among young children,
and the disease affects the productivity and thereby economic
growth of Malagasy and Comoran families, new measures to
control the disease are embraced. However, infectious
disease experts are concerned about potential human rights or
ethical violations in addition to population health concerns.
In an effort to provide technical guidance, the GOM
permitted the local research institution, Institut Pasteur,
and the Roll Back Malaria team (including one USG malaria
advisor from the Center for Disease Control and Prevention
(CDC)) to negotiate the details of the study with members of
the research team from Ghangzou University of Traditional
Chinese Medicine (GUTCM). End summary.

Malaria in Madagascar
--------------


2. (U) Madagascar is a malaria endemic country with as much
as 90% of the population exposed to permanent or seasonal
malaria transmission, becoming infected multiple times
throughout the year. In 2005, the Ministry of Health (MOH)
recorded over 2 million cases of malaria, nearly one-fifth of
which ended in death. Recent data show a reduction in
malaria cases; malaria has fallen to the 2nd or 3rd disease
most frequently diagnosed during consultations at hospitals
or health centers. While the incidence of malaria has
decreased over the past couple of years due to improved
coverage of malaria interventions, the disease persists and
it is still the leading cause of death among children under
five years of age.


3. (U) The United Nations Secretary General Ban Ki-Moon
called for universal coverage of all malaria interventions
which include the use of long-lasting insecticide treated
nets (LLIN),routine indoor residual spraying (IRS),
intermittent preventive treatment during pregnancy (IPTp),
rapid diagnostic tests (RDT),and prompt treatment using
antimalarial drugs. Madagascar receives funding, technical
support, and the aforementioned health commodities from the
Global Fund to fight AIDS, TB, and Malaria (GFATM) and the
USG Presidential Malaria Initiative (PMI) to conduct a
variety of intervention strategies tailored to the incidence
of malaria and environmental causes.

Mass Drug Administration
--------------


4. (U) The Government of Madagascar (GOM) recognizes the
threat of malaria in its own ambitious Madagascar Action
Plan, which outlines development goals for the country.
Through decreasing the number of cases and deaths due to
malaria, the GOM hopes to work towards its elimination. In
fact, malaria was eradicated from 1949 to 1959 through
treating children with chloroquine and killing mosquitoes
with DDT. At present, traditional ways to eradicate malaria
focus on using LLINs to protect humans from being bitten or
by using IRS to kill mosquitoes.


5. (U) Li Guoqiang, a pharmaceutical researcher from the
GUTCM, is looking at it differently. He aims to eradicate
the malaria parasite from humans by doing mass drug
administration (treating all individuals, not just those who
are infected) with Artequick),a pill that contains both the
World Health Organization (WHO)-recommended Artemisin
Combination Treatment (ACT) and primaquine. In fact, most
malaria infections are asymptomatic, thereby often going
untreated. When a mosquito bites a human who is a carrier of
the malaria parasite, the mosquito becomes infected and can
then transmit malaria to someone else. Thus, the hypothesis
of mass drug administration (MDA) - if all humans in a
contained area, such as an island, are treated with
antimalarials, then the parasite source, humans, may cease to
be carriers.


6. (U) MDA has been attempted since the 1920s and each time
has led to a decrease in the prevalence of the parasite in
human blood as well as a reduction in the number of people
infected with malaria. Not only is it difficult to deliver
MDA but there are concerns that such widespread use could
lead to drug resistance. None of the trials have resulted in
complete interruption of malaria transmission, except for one
case. In 1996, the people of Aneityum, Vanuatu completed
eight rounds of MDA in addition to continued use of ITNs and
other environmental controls; this led to the elimination of
malaria from the small island found in the South Pacific
Ocean. A major challenge of MDA is that anyone entering the
area has the potential to spoil the 100% malaria-free zone,
thereby making control and surveillance vital to the success
and sustainability of such an endeavor. The population of
Aneityum has remained malaria free, in part, some say, to the
ongoing malaria monitoring efforts.

Chinese Study Comes to Madagascar
--------------


7. (U) GUTCM, located in southern China, was founded in 1956
and continues to be governed by the state. As one of the
four oldest colleges of its kind, its reputation as a
research base in the field of Clinical Pharmacology,
authorized by the Chinese Ministry of Public Health, is
growing. Recently, GUTCM has conducted several studies
delivering MDA of Artequick),seeing success in two remote
areas of Cambodia as well as its most recent trial in the
Comoros. In the Comoros in 2008, nearly 50% of the people on
the island of Moheli were carriers of the parasite; the most
common cause of death for children under the age of 5 was
malaria. The MDA to MoheliQ,s 40,000 residents resulted in
reducing malaria cases from 23% to 1.4% within the first two
months of treatment. However, inadequate regulation and lack
of treatment plans in place for the fishermen and traders
that frequently travel between the Comoran islands threaten
the sustainable impact of this MDA trial.


8. (U) In Madagascar, China's development programs also focus
on combating malaria (reftel). GUTCMQ,s Principal
Investigator Jian-Ping Song aims to use similar methodology
in Madagascar as in Comoros by delivering MDA during a 2-year
pilot study in Nosy Be, a small island 15 kilometers off the
northwest coast of Madagascar. The Nosy Be district hospital
measured an average of 17,492 cases of malaria per year,
affecting nearly 1 in 3 residents. The study population will
include all Nosy Be residents (population near 49,000) over
six months of age. In addition, sentinel surveillance sites
will be included at the airport and port to ensure that all
people entering Nosy Be are receiving treatment. Researchers
intend to establish a Malaria Control Center to train
community health volunteers, manage and analyze data, and
develop a reporting system; supply all study sites with
laboratory centers complete with diagnostic microscopic
equipment and at least one to two lab technicians; train
community health volunteers, one or two per 300 residents, to
supervise medication administration with 100% coverage; and
provide free diagnostic and malaria treatment services.

Human Rights and Ethics
--------------


9. (U) Made up of doctors, researchers, and public health
experts from the USG Center for Disease Control and
Prevention (CDC),the World Health Organization (WHO),
UNICEF, and the World Bank, the Roll Back Malaria (RBM)
technical working group found several human rights and
ethical issues of concern regarding the research protocol.
First, bioethics measures include informed consent
(willingness to participate, knowledge of study, information
at the appropriate literacy level). The success of MDA is
dependent on most of the residents taking part in the study
without coercion and with an explanation of all potential
benefits and risks. Second, there are drug safety concerns
with the inclusion of pregnant women and children less than
six months of age, something the GUTCM team is pressing .
Safety and effectiveness of some antimalarial drugs have not
been established for children and pregnant women, and there
are contra-indications in children for primaquine, one of the
components of Artequick). Third, the study includes the
cessation of ALL other prevention and control measures
(LLINs, IRS, etc.) which, at its conclusion, would still be
helpful in retaining sustainable morbidity reduction.
Especially as Nosy Be is a prime domestic and international
tourist destination with one international airport and one
maritime port, there is heavy traffic flow in and out of the
island and a re-emergence of malaria is plausible without
ongoing control measures. Finally, with mass treatment there
is the possibility of developing drug resistance.
Inadequate dosing, incomplete course of therapy, and
inappropriate drug use contribute to the emergence and spread
of drug resistant-parasites. This already occured with
respect to the former malaria treatment widely used in
Madagascar, chloroquine, for which parasites have developed a
high level of resistance (40%).

Comment
--------------


10. (U) As seen in other pilot studies, specifically in
Vanuatu and possibly the Comoros, MDA has the potential to
eradicate malaria in small, remote island nations. Nosy Be,
a tourist hot spot, is not as isolated as the former two
examples. The biggest threat to the success of MDA in
Madagascar is controlling malaria from being reintroduced in
Nosy Be, hardly an easy feat considering that a large number
of tourists come from Madagascar, currently a breeding ground
for malaria. Though infectious disease experts do not
recommend this as a malaria prevention and control strategy
in Madagascar at this time, the GOM has agreed to proceed as
a result of political pressure. With certain control
measures recommended by the international malaria experts
making up the Roll Back Malaria team, the primary human
rights and ethical concerns will be raised and hopefully,
abated. End comment.


MARQUARDT