W poprzedniej części artykułu przedstawiliśmy treść webinaru poprowadzonego przez Christiana Rassi na temat programu SMC – sezonowej chemoprewencji malarii. Poniżej przedstawiamy odpowiedzi Christiana na interesujące pytania zadane przez słuchaczy podczas spotkania. Całość nagrania, wraz z częścią poświęconą pytaniom od publiczności, możecie znaleźć na naszym oficjalnym kanale YouTube.
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Has COVID-19 affected the SMC delivery? How did COVID-19 impact projects across your organization? What challenges was/is Malaria Consortium facing?
As I hinted towards the end of my presentation, COVID has had a massive impact on our programs, including SMC. I’m very proud to say that SMC campaigns have not been interrupted. They weren’t last year and they haven’t been interrupted by COVID-19 this year. But making that happen required immense efforts of everyone involved.
You have to imagine – when WHO declared the COVID-19 outbreak, a pandemic, in round about March last year, preparations for the 2020 campaign were already well underway, so we really didn’t have much time to respond. But Malaria Consortium, in line with World Health Organization recommendations, took the position very early on that SMC is an essential health service and that discontinuing SMC because of COVID would risk a substantial increase in malaria cases and deaths among children under five, which would put additional pressure on health systems that would already be under immense strain because of COVID-19. We decided very early on that we should do whatever we can together with our partners to make sure that SMC would continue.
We got together with WHO and others and we developed some operational guidance around the safe delivery of SMC, factoring in infection prevention and control measures – like hand washing, wearing a face mask, keeping physical distance between the implementers and the beneficiaries. Then we developed tools to help implementers adhere to those guidelines with things like job aids for community distributors that illustrate how to keep physical distance while you’re administering a drug to a community member. Other things that we did were moving a lot of the in-person meetings online, including some of the trainings that were delivered virtually.
I should mention that all of that, of course, came at a cost. We had to invest quite substantially into COVID-19 related commodities, like face masks or hand sanitizer. To make a campaign of that scale possible, there was a huge procurement effort involved in making sure that enough masks, for example, and enough hand sanitizer was available for all the implementers. As I said, we were able to keep the SMC campaigns going. We’re not aware of any major contributions to COVID-19 outbreaks through the SMC campaign, so we think we’ve managed to keep everyone involved reasonably safe.
Of course, we learned from what we did last year. We applied the lessons this year – we changed our guidance slightly to make it easier for people to adhere to the guidelines, but the general principle remains the same. There are a lot of risk mitigation measures still in place to make sure that both the implementers, but also the communities are as safe as possible.
That was using SMC as an example of all our work, but I think it illustrates the challenges that Malaria Consortium faced across all our programs and all our projects. There was an immense effort that went into defining appropriate infection prevention and control measures to make sure that the projects were able to keep going.
Considering seasonal changes – how many doses a year of this medicine does one child need to get to be fully protected? In other words, what’s the calculated cost per year?
The standard model is four monthly full doses of the two anti-malarial medicines that we’re using in SMC. Some countries have started looking at the seasonality patterns and there are areas where the malaria season is slightly longer – say, five months instead of four months – and they’ve now gone to implementing five cycles of SMC in those areas. At the moment, a rough split is: 85% of all the children who are receiving SMC are getting four cycles, maybe about 15% are receiving five cycles. I think that’s probably going to increase slightly in the future, so maybe it will go to one quarter receiving five cycles and the remaining three quarters receiving the traditional four cycles.
The cost of adding an additional cycle is actually not that high, however there’s a cut-off at some point. There’s a cut-off both from the cost side, but also from the effectiveness and the safety side. If you start giving it too often – there are safety concerns. You couldn’t give it every month of the year (for forever, basically). So there will be safety concerns, but also it would no longer be cost effective. The current modelling shows that five cycles is still cost effective, but going to six cycles in areas where the transmission is even longer – would probably no longer be cost effective.
The $3.60 per year and cycle – that was a figure for four cycles. It actually was for a couple of years ago, now we’re probably sitting at round about $4 per year and per child at the moment, so adding another cycle will maybe add another $0.50 total.
Is the dose for adults the same as the dose for children, or is it higher?
The intervention is focusing on children under five. There are discussions about expanding it to children under ten, but no one’s doing that at the moment. Personally, I have my doubts about that. For now, SMC is only delivered to children under five.
There are two dosing regimens for different age groups within that: there’s a lower dose for children up to one year and then there’s a slightly higher dose for children between one and five years. There’s also a small cost difference between those two.
How did the pandemics actually influence the prices? Because we know that everything went up.
In general, the cost for the drugs hasn’t changed because of the pandemic. The general cost of implementing, in the sense of paying the distributors etc. – that hasn’t changed. What has changed is the addition of the infection prevention and control measures.
Previously we didn’t have to procure face masks for SMC. Previously we didn’t have to procure hand sanitizer for SMC. That has increased the cost quite a bit. I don’t have any accurate unit costs that I could share and we only have this one year of cost data. I would expect the costs to come down a little because I think we all have to contend with the fact that COVID will be around for some time and we’ll have to deal with it for some time to come. But that was the main cost impact.
I should probably also mention that in some respects COVID made the intervention cheaper, because we could travel less. I haven’t been to any of the SMC countries in the last two years now. Obviously that’s only a small, tiny portion of the overall cost, but it’s something. Some of the trainings went online, so rather than paying for people to come to a training – when you pay for the venue, for DMs, etc. – you just pay for a Zoom license. That sort of reduced the cost.
Overall, the increase was much higher than the cost savings, though. But as I said, I can’t give you any reliable costing data.
In the philanthropy report[1] we do talk about the overall cost of SMC and we do provide an overall amount for what we think we’ve invested in things like face masks etc. That’ll give you an idea, but don’t read too much into it as it’s data from one year, and it was the most unusual year with all the experience.
Could SMC be replaced by a malaria vaccine one day, as there is now a vaccine with a 70+ percent efficiency available? Is Malaria Consortium looking into broadening efforts into vaccination campaigns as well?
The question of how the vaccines might affect SMC in the longer term is a very difficult question to answer with any degree of confidence at this stage, but I’ll tell you what my thoughts are at this point in time.
As you say, there are various vaccines in the pipeline. One’s been around for quite some time now – it’s called the RTS,S vaccine. The efficacy results have been a bit of a mixed bag, to be perfectly honest. Currently, it hasn’t been recommended for scale-up by the World Health Organization – yet!
The other vaccine that I think you’re probably referring to, with the 75% statement – that has made the news recently because researchers just published results from a trial that was conducted in Burkina Faso, I believe. The vaccine doesn’t have an established name yet. I’ve heard it referred to as “the Oxford vaccine for malaria”. The study looked very robust and the results looked very promising. That’s very good news. However, so far that’s based on just this one study with a fairly small sample of children. I think there’s quite a lot of research that still needs to be done before we can speculate about the potential role of this vaccine in the fight against malaria. Of course, if COVID has taught us anything, it’s that research on vaccines can be fast- tracked, so maybe it’s going to happen faster than I currently think. But I would say it’s probably a few years down the line.
I also know that there’s other researchers who’ve been doing some research in Burkina Faso and Mali, looking at combining the RTS,S vaccine and SMC. They’ve published a protocol for that trial – they haven’t published the results yet, so I can’t say much about it. We were told the publication of the results is imminent, but I haven’t seen them. We’ve also been told that the results are promising, but again – I haven’t seen them.
In the medium term, a scenario I think is realistic is a combination of a vaccine and SMC as a potential strategy in the future. So it’s not necessarily an “either-or”, but rather a bit of both. I think that’s the most likely longer-term strategy. But again – that’s looking into a crystal ball. I think it’s a bit too early to say that with any degree of confidence.
When it comes to the future of fighting malaria – what are the developments you are looking forward to the most? Vaccines? Gene drives? More access to medical services? Which areas of basic malaria research are the most neglected in your opinion?
The broader question was, what are other innovations that we’re looking forward to. The vaccines to me would be a number one. I think there’s also innovation needed in terms of new and effective antimalarials, for treating malaria infections. And probably as important, even though it gets forgotten about quite easily, is the diagnostic tools. Easy to use, reliable tools to diagnose malaria at the community level – that would really transform the way we treat malaria.
A bit more out there in the R&D space is what’s called monoclonal antibodies. I’m certainly not an expert on that, I can’t really say much about it, but that is another buzzword that you will hear when you’re listening in on discussions about the future of malaria. All of these, though, are a couple of years down the line, so in the medium and in the short term – as I said in my talk – I think what we really need to focus on is using the tools we already have. We have good tools already at our disposal. We need to get better at using them, using them smartly and making sure that people actually have access to those tools.
What has been your experience working with GiveWell and the Effective Altruism community?
That’s a very good and very interesting question. I hope I managed to get across in my talk that I can’t overemphasize the role philanthropic funding has played in scaling up SMC across the Sahel. Back in 2015 – 2017, there was an initial scale-up project which was funded by UNITAID. It was led by Malaria Consortium. It established SMC in seven countries, reaching about 7 million children at the time. That project generated some of the evidence that SMC can be delivered at scale and effectively, but it typically takes a while for the large institutional donors to pick up on that evidence, to build it into their models and build it into their future funding streams. Fortunately, around the time this project ended in 2017 – philanthropic funding for SMC became available through GiveWell, which has allowed Malaria Consortium to maintain and to even grow the scale of SMC, as I showed in my talk. So we’re now reaching about 20 million children – just as Malaria Consortium.
And even now, when some of the traditional funders – in particular the Global Fund – have bought into SMC and have substantially increased the funding for SMC, I think there is still an important complementary role for philanthropy. As I said during my presentation, for us, for Malaria Consortium, it’s the planning, security and the operational flexibility that’s transformational for the way in which we work. I gave you the example earlier of being able to support Borno state in Nigeria this year, making sure that two million additional children are protected from malaria – it wouldn’t have been possible to do that in a traditional institutional funding arrangement. Having this philanthropic funding available is absolutely transformational for us. There are a lot of other examples I could cite and we’re really, immensely grateful to all our supporters from GiveWell and the effective altruism community.
Now, when we think about the challenges… I would say it’s taken us, as public health practitioners, some getting used to the approach and the thinking behind GiveWell’s work and the effective altruism approach. You obviously have a very clear focus on cost effectiveness, whereas public health NGOs, like Malaria Consortium – we tend to look at things more from a health system strengthening point of view. So sometimes when we’re having discussions with GiveWell, that’s almost like a clash of philosophies, if you like – a philosophical clash between their thinking and our thinking. However, we have a very, very constructive working relationship with GiveWell, with other effective altruists, with other Effective Altruism organizations in other countries. They tend to ask a lot of questions, but whenever they do that I can genuinely say that they are always helpful and that they prompt us to think things through from a slightly different angle, which I find a very enriching experience.
Ufamy, że spotkanie z Christianem pozwoliło Wam lepiej zapoznać się z działaniami Malaria Consortium oraz z jej programem sezonowej chemoprewencji malarii. Gorąco zachęcamy do śledzenia zarówno ich, jak i naszej aktywności.
– Redakcja EA Polska
bibliografia:
[1] Malaria Cosortium’s seasonal malaria chemoprevention program: philanthropy report 2020. London: Malaria Consortium; 2021.