history of malaria treatment in madagascar · history of malaria treatment in madagascar ......

Ministry of Public Health

History of Malaria TreatmentHistory of Malaria Treatment

in Madagascarin Madagascar

Milijaona RANDRIANARIVELOJOSIAMilijaona RANDRIANARIVELOJOSIA, PhD, HDR, PhD, HDR

ARTEMISININ CONFERENCE 2010Joint WHO/RBM/MMV meetingJoint WHO/RBM/MMV meeting

Supported by DFID, UKArtemisinin – The Future

12th – 14th October 2010 in Antananarivo, Madagascar

Origin of malaria in Madagascar:Origin of malaria in Madagascar:linked to the human population settlementlinked to the human population settlementlinked to the human population settlementlinked to the human population settlement

Origin of the human population Origin of the human population in the southin the south--western part of the western part of the

I di OI di OIndian OceanIndian Ocean

On the basis ofOn the basis of-- laguagelaguage-- agricultural practiceagricultural practice-- archeological dataarcheological data-- archeological dataarcheological data-- genetic studygenetic study-- traditional habittraditional habit

Source : Biodiversité Source : Biodiversité du paludisme dans le mondedu paludisme dans le monde

“Malaria” known by Malagasy“Malaria” known by Malagasy

(page 73)(page 73)

Tazo Tazo (fever, chill, headache, fatigue …) (fever, chill, headache, fatigue …) is not only malariais not only malaria

Malaria history in Madagascar: Malaria history in Madagascar: myth, legend and realitymyth, legend and reality

InIn thethe pastpast

OralOral traditiontradition priorprior toto thethe EuropeanEuropean arrivalarrival

ForFor aa tribetribe fromfrom thethe southernsouthern highlandhighland :: “Man“Man isis thethe oneone whowho survivessurvivesForFor aa tribetribe fromfrom thethe southernsouthern highlandhighland :: ManMan isis thethe oneone whowho survivessurvivestazotazo (fever)(fever) inin thethe costalcostal areas”areas”

AA powerfulpowerful QueenQueen saidsaid :: ““HazoHazo (trees)(trees) andand tazotazo (fever)(fever) areare thethe protectionprotectionff thth ki dki d DD tt thth d”d”ofof thethe kingdomkingdom.. DoDo notnot openopen thethe road”road”

Madagascar,Madagascar, cemeterycemetery forfor EuropeansEuropeans inin thethe pastpastFeverFever asas killerkiller inin thethe costalcostal areasareas asas inin XVIXVI centurycenturyFeverFever asas killerkiller inin thethe costalcostal areasareas asas inin XVIXVI centurycenturyFeverFever asas killerkiller duringduring thethe FrenchFrench militarymilitary campaigncampaign inin 18951895

Si h h d lSince the XX century: much more modern tools tocombat malaria in Madagascar

People naturally live with malaria in MadagascarPeople naturally live with malaria in MadagascarPeople naturally live with malaria in MadagascarPeople naturally live with malaria in Madagascar

PreventionPreventionPreventionPreventionTraditionalTraditional methodmethod:: burnburn aromaticaromatic plantplantModernModern methodmethod:: bedbed nets,nets, drugs,drugs, repellent,repellent, indoorindoorModernModern methodmethod:: bedbed nets,nets, drugs,drugs, repellent,repellent, indoorindoorsprayingspraying ofof insecticide,insecticide, modernmodern househouse

TreatmentTreatmentTraditionalTraditional medicinemedicine:: plants,plants, exorcism,exorcism, prayersprayersTraditionalTraditional medicinemedicine:: plants,plants, exorcism,exorcism, prayersprayersModernModern drugdrug inin:: selfself medicationmedication atat home,home, recommendedrecommendedinin--homehome managementmanagement ofof fever,fever, massmass treatment,treatment, healthhealthf ili if ili i i ii i iifacilities,facilities, intermittentintermittent preventivepreventive treatments,treatments, ……

Madagascar Madagascar priorprior to the XX to the XX centurycentury : far : far awayawaygg pp yy yy

World Malaria Report 2008, WHO/HTM/GMP/2008.1World Malaria Report 2008, WHO/HTM/GMP/2008.1

Evolution of history of malaria treatment in Evolution of history of malaria treatment in Madagascar: linked to natural and political history ofMadagascar: linked to natural and political history ofMadagascar: linked to natural and political history of Madagascar: linked to natural and political history of

the Islandthe Island

Source : Portuguese Nautical Atlas (1519)Source : Portuguese Nautical Atlas (1519)

Evolution of the malaria treatment in MadagascarEvolution of the malaria treatment in Madagascar

Traditional medicine (plants)

Remedies and drugs

1 1980 200519451900 2011

Treat empirically

Time line1 1980 200519451900 2011

Traditional medicine (plants)Traditional medicine (plants)

ToTo treattreat feverfeverSingleSingle plantplant oror mixturemixture ofof plantsplantsSingleSingle plantplant oror mixturemixture ofof plantsplantsInIn thethe village,village, atat thethe supermarketsupermarketSelfSelf medicationmedication oror prescribedprescribed

Combined with standard drugs Strychnos myrtoides + CQ

MalagashanineMalagashanineCQ-R reserser

Available for research on any fever related pathologies



Q i i d Ci h l t tiQuinine and Cinchona plantation

Remedies and drugs

Selective

1 1980 200519451900 2011

Treat empirically Selective cure

Time line1 1980 200519451900 2011

CinchonaCinchona sp: neglected plantations ?sp: neglected plantations ?

Northern site2006

Eastern foothill areaEastern foothill area2009




CQ followed by synthetic drugs

Remedies and drugs

Selective Cure and

1 1980 200519451900 2011


Cure and prevent

Time line1 1980 200519451900 2011

Evolution of Malagasy population Evolution of Malagasy population between 1900 and 2005 between 1900 and 2005 (X1000)(X1000)( )( )

ddDDT and DDT and ChloroquineChloroquinemassive usemassive use

Gastineau B., Rakotoson L. (2005). Evolution de la population à Madagascar. Travaux etDocuments, n°5, Programme 4D, Institut Catholique de Madagascar et IRD, 14p., Antananarivo.

1980s : last malaria outbreak in Madagascar1980s : last malaria outbreak in MadagascarWhy did it happen ?Why did it happen ?Why did it happen ?Why did it happen ?

SinceSince 19451945 ::CQCQ toto treattreat andand toto preventprevent malariamalaria

ll ll DDTDDT i di d ii ((19491949))++ largelarge scalescale DDTDDT indoorindoor sprayingspraying ((19491949))

19521952 –– 19711971 ::CQCQ forfor chemoprophylaxischemoprophylaxis inin childrenchildrenQQ p p yp p y

19711971 –– 19751975//7979 :: irregularirregular chemoprophylaxischemoprophylaxisInterruptionInterruption ofof DDTDDT indoorindoor spayingspayingInterruptionInterruption ofof DDTDDT indoorindoor spayingspayingCollapseCollapse ofof thethe economyeconomyErosionErosion ofof thethe healthhealth systemsystemLackLack ofof chloroquinechloroquine (lack(lack ofof funding)funding)

19801980ss ::malariamalaria outbreaksoutbreaks (increasing(increasing malariamalariath h tth h t thth tt ithith f t lf t lcasescases throughoutthroughout thethe country,country, withwith moremore fatalfatal

casescases inin thethe highland)highland)





Generic CQ

Remedies and drugs

Selective Cure and Epidemy

1 1980 200519451900 2011


Cure and prevent

Epidemycontrol

Time line1 1980 200519451900 2011

1980s : last malaria outbreak in Madagascar1980s : last malaria outbreak in MadagascarHow was organized the repost against it ?How was organized the repost against it ?How was organized the repost against it ?How was organized the repost against it ?

Chloroquinisation campaignChloroquinisation campaign (intensive in 1988/89)(intensive in 1988/89) and DDTand DDT

Sign attached to announce the sale ofchloroquine during the chloroquinisationcampaign to respond to the last malaria epidemicin Madagascar. (Milijaona & Donatien, 2005)

Recent use of Recent use of chloroquinechloroquine in Madagascarin Madagascar

Marketing socialMarketing social(0.025 USD)(0.025 USD)

Free of chargeFree of charge

Massive distribution of Massive distribution of chloroquinechloroquine for infor in--home management of home management of feverfever in children since 2003in children since 2003feverfever in children since 2003in children since 2003

ComorosComoros (>70%)(>70%)Low prevalence of Low prevalence of pfcrtpfcrtmutantmutant P falciparumP falciparum

SambavaSambavaAntsohihyAntsohihy

mutant mutant P. falciparumP. falciparum

Ste MarieSte Marie

AndapaAndapaAntsohihyAntsohihy

MahajangaMahajanga

mutant mutant pfcrt pfcrt detecteddetected TsiroanomandidyTsiroanomandidyAntananarivoAntananarivo

SaharevoSaharevo

Ste MarieSte Marie

Where is IPMWhere is IPM

R d i i l j i M t lR d i i l j i M t lMadagascar Madagascar

(<3%)(<3%)

Randrianarivelojosia M et al. Randrianarivelojosia M et al. Trans R Soc Trop Med Hyg. 2006Trans R Soc Trop Med Hyg. 2006





Generic CQ

ACTs and AARemedies and drugs

ACTs and AA

Selective Cure and Epidemy Malaria

1 1980 200519451900 2011


Cure and prevent

Epidemycontrol

Malaria elimination

Time line1 1980 200519451900 2011

ACT: first steps since Dec 2005ACT: first steps since Dec 2005

FirstFirst lineline treatmenttreatmentA t tA t t di idi i (ASAQ)(ASAQ)ArtesunateArtesunate ++ amodiaquineamodiaquine (ASAQ)(ASAQ)

WhatWhat isis donedone ??

artemisininartemisinin

WhatWhat isis donedone ??ProgressiveProgressive introductionintroduction withwith coco--blisterblister inin 20062006FullFull coveragecoverage todaytoday withwith ASAQASAQ FDCFDCgg yy QQACTACT efficacyefficacy confirmedconfirmed

QuestionsQuestions:: AvailabilityAvailability ofof ACT?ACT? forfor howhow longlong ??

History of Malaria Treatment in Madagascar:History of Malaria Treatment in Madagascar:

What is next ?What is next ?What is next ?What is next ?

Key for malariaKey for malaria eliminationelimination in Madagascarin MadagascarKey for malaria Key for malaria eliminationelimination in Madagascarin Madagascar

EnvironmentEnvironment

MalariaMalariaVectorVector ParasiteParasiteMalaria Malaria endemicityendemicity

VectorVectorAutochthonous or importedAutochthonous or imported

ACTsACTsNets (LLIN)Nets (LLIN)

Indoor sprayingIndoor spraying

HumanHuman

DiagnosisDiagnosisp y gp y g

«« It It isis time for time for artemisininartemisinin »»

BionexxBionexx banner banner promotingpromoting Artemisia annuaArtemisia annua cultivationcultivationwithwith a a specialspecial focus on focus on outgrowersoutgrowers

I I dedicatededicate thisthis talk totalk to

Mrs Marcelline Mrs Marcelline RazanamparanyRazanamparany(former(former presidentpresident of theof the RedRed Cross)Cross)(former (former presidentpresident of the of the RedRed Cross)Cross)

for the for the successfulsuccessful chloroquine chloroquine campaigncampaignqq p gp gsheshe ledled in rural areas (1950 in rural areas (1950 –– 1971) 1971)

sheshe savedsaved life for millions of life for millions of childrenchildren

93 yrs in 2005

Ministry of Public Health

History of Malaria TreatmentHistory of Malaria Treatment

in Madagascarin Madagascar

Milijaona RANDRIANARIVELOJOSIAMilijaona RANDRIANARIVELOJOSIA, PhD, HDR, PhD, HDR

ARTEMISININ CONFERENCE 2010Joint WHO/RBM/MMV meetingJoint WHO/RBM/MMV meeting

Supported by DFID, UKArtemisinin – The Future

12th – 14th October 2010 in Antananarivo, Madagascar