MALARIA COMMUNITY FORUM IN CENTRAL AFRICA: "Surveillance Tools for the efficacy of Antimalarial drugs"

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The Malaria community Forum in central Africa took place from 6th to 8th June 2011 at Marina hotel, Brazzaville-Congo. This meeting co-organized by CANTAM (Central Africa Network on Tuberculosis, HIV/AIDS and Malaria) and WWARN (Worldwide Antimalarial Resistance Network) under the theme: “Surveillance Tools for the efficacy of Antimalarial drugs” aimed at bringing together the main actors in the war against malaria to work out a common strategy and define straight forward steps to reinforce surveillance networks and capacities and to get all the actors to work in synergy to achieve better results. The opening ceremony was lead by our hosts: Prof. Francine NTOUMI (CANTAM’s coordinator), Prof. Philippe Guerin (WWARN Managing Director) and Congo’s minister for Scientific Research. Prof. NTOUMI gave a feedback from the last malaria world day (on April 25th) which highlighted the fact that though some countries had succeeded in reducing their malaria burden by 50 %, there were still too few efforts made in term of: - Surveillance of the malaria disease and antimalarial drug usage - Implementation of regulatory measures - Adequate follow up of resistance to malaria parasite The new challenge for scientists is therefore to establish and implement standardized methods to collect, analyse and interpret available data on resistance and send them back to governments with a clear road map that would enable them take relevant decision based on local indicators. To succeed in this task, Prof. Ntoumi emphasized that there was a need for researchers to find financial support outside of government organizations in order to develop research activities linked with surveillance of antimalarial network (just like her institution succeeded to do with the support of TOTAL Congo). while acknowledging the progress made in the past decade in the fight against malaria (introduction of ACTs therapy, use of impregnated bednets and the fight against resistance with the withdrawal of mono-therapy) which resulted in a significant reduction in mortality, Prof. Guerin however stated that these progress were not homogeneous and there was a need to generate a more reliable health surveillance system through regional collaborations, with accessible information in real time to track the emergence and spread of antimalarial drug resistance. Congo’s minister for Scientific Research concluded this opening ceremony in a note saying that malaria is both a major preoccupation for the government, and a challenge for scientific research. Consequently there is a need to bring efforts and competencies together in order to tackle this new challenge. For this reason, Congo’s ministry for Scientific Research will gladly get involved in this initiative, contributing thereby to the country’s effort towards being an emerging country by 2025. The Minister also congratulated the researchers for choosing Brazzaville for this first forum, which he viewed as a signal of progress in terms of networking and collaboration, emphasized the need to come up with a clear road map to tackle this fight against malaria and ended his speech by encouraging partners to come up with appropriate recommendations from their meeting. Summary of Sessions The meeting included four main sessions covered in three days and ended with the identification of gaps and laying out of recommendations on the next steps to take regarding the fight against resistance to anti-malaria. The first session titled: “Surveillance of therapeutic efficacy of antimalarial”, consisted of a series of presentations introduced by Dr. Soce Fall from the W.H.O who presented a general state of malaria in different countries of Central Africa, namely: Angola, Cameroon, Congo, Gabon, Equatorial Guinea, Central Africa Republic, Chad and Sao Tome and Principe. Then CANTAM and WWARN initiatives presented their networks, followed by Dr. J Bigoga from Cameroon, Prof. Marielle Bouyou and Dr. JB Lekana-Douki from Gabon, Dr. Mathieu Ndounga from Congo Brazzaville and Dr. Gaston Tona Lutete from Democratic Republic of Congo who shared some results from efficacy studies going on in their respective centres. This session ended with general discussions aimed at identifying the needs to be met and the expertise available within the sub-region, to conduct reliable studies on therapeutic efficacy. Some interesting recommendations were made: - To henceforth invite the president of the Governing body of pharmacist to these meetings to ensure that pharmacists are up to date with research findings for a better health care delivery (e.g. stopping the prescription of mono-therapy) - To create strategic groups who will come upon with innovative ideas to promote awareness and the need to stop mono-therapy against malaria - To resort to mobile and smaller devices for testing the quality of drugs in circulation in our countries in the absence of quality control laboratories. - To stop the habit of prescribing antimalarial drugs to patient without a proper diagnosis - To reinforce regional collaborations between stronger and weaker research institutions in terms of meetings, trainings, capacity building, and sharing of techniques and methodologies. - To create sentinel sites in some countries to observe the emergence of resistance and to run efficacy studies on ACTs, knowing that mosquito does not need visa to cross borders. The second session titled: “surveillance and control of antimalarial-ethical consideration” was a very interesting session as it gave us the opportunity to hear about relevant topics in term of regulation, quality control and data management. - A W.H.O representative gave recommendations regarding: reinforcement of the authority of pharmaceutical regulation bodies, the follow up of newly introduced drugs, the need to train staffs and to set up or optimize drugs quality control labs. - Pr. Honoré Tsiba from Brazzaville University Hospital explained clearly the ethical principles guiding clinical research (autonomy; beneficence; non maleficence; justice) to which he added the cultural aspect especially in Africa, and explained the constitution of National Ethic Committees which should be independent from the authorities in order to give impartial decisions. - Dr. Ambrose Talisuna from WWARN gave a brilliant presentation on the utilization of antimalarial drugs, and the necessity to be extra careful about the drugs currently in circulation in most African’s markets, due to the fact that a great number of them were either counterfeit or of low quality. In addition, the packaging of counterfeit drugs has so improved lately that it becomes almost impossible to say which one is genuine (with the damaging effect we know on the patients treated with those). - Clarissa Moreira from WWARN finally presented a data management tool which researchers can take advantage of to clean, edit and present their data and results in a professional format. This session ended with the constitution of two working groups whose task was to come up with resolutions on the following topics: - Determining the technical expertise (human resource) in the sub-region, including the material and equipment needed to enable the generation of information on efficacy of antimalarial drugs. - Training on data management and statistical resources tools elaborated by WWARN. The third session titled: “Laboratories capacities for surveillance studies on antimalarial drugs (in vitro, molecular and pharmacological studies)” was also a good ground for discussions. - The presentation from DRC, created a good opportunity to assess the progress of African research institutions in term of in vitro and molecular testing and more importantly the interpretations of these results in comparison to in vivo studies. Some limitations in term of equipment, quality control and quality assurance were highlighted as well as capacities in term of data management, and the implication of W.H.O Afro and governments through their national programs were questioned. It was generally agreed that: • Collaboration should be reinforce between national programs and research institutions • There was a need to create a more direct access to W.H.O country representing bodies in order to improve communication, and upgrade the chances to generate more funds in this area • Methodologies, techniques and interpretation of vitro /in vivo study’s results should be standardized in order to be unequivocal prior to their publication. - Dr. José Tchofa from USAID/DRC, in his quality of special adviser of the president of the Global Health Initiative shared the GHI experience on efficacy surveillance, and enlightened the participants about this project initiated by president Bush to help some target countries in their fight against malaria (Benin republic, Ghana, Mali, Kenya, Liberia, Madagascar, Zambia and Ethiopia). We also learned about criteria needed to follow in order to join the target group, just like Guinea and Zimbabwe were currently trying to do. Dr. Tchofa emphasized that though the burden of the disease, good governance (ability to convey the funds to the real beneficiaries), the presence of USAID (USA technical platform), and support of other financial partner (i.e. previous grants from I.M.F) were qualifying criteria to enter the group, the proximity of a target country (due to the risk brought by inter regional movement of populations) could also be considered while assessing a candidate profile for selection. However, he stated that it was the neighbour country’s responsibility to agree with the target country to go back to the funders to solicit for a regional alliance. It is also the responsibility of National programs against Malaria to collaborate with research institutions in neighbouring countries, to make sure that the efforts of some are not cancelled by the lack of actions of others. - Finally, the Global Health Trials coordinator for west Africa and WWARN Managing Director were given a chance to present their institutions and the impact both were having in term of: information sharing; networking; trainings; career development; data management; harmonization of techniques, which they are freely offering through their website platform on internet, and their physical activities in the countries through their regional faculties and representations. The fourth and last session titled: “interactions with regional and international initiatives” was an opportunity for Prof. Andrew Kitua from TDR/WHO Geneva, to present the research and Training in Tropical disease program, followed by the presentation by the reporters of the list of recommendations and resolutions from the two working groups regarding the gaps identified and the next step to take to bring this initiative forward. By the end of the meeting, the participants had come up with straight forward resolutions for the future, some of them being: - To enlarge CANTAM network (currently comprising research institutions from Congo, Gabon, Cameroon and Tubingen University in Germany) to some other countries of the sub region. The very practical way to achieve this should be through concrete collaboration in answering international calls for future grant. - To plan regular working sessions between research institutions, national programs and WHO country offices and collaborative applications (from regional networks) when responding to calls for research grants. - To ensure mutual communication within research institutions and National Programs in order to fit research needs in the budget of National programs prior to their approval by governments. - To harmonize and share the results of studies across boundaries in neighbouring countries was also mentioned for the common interest of all the parties involved. - To initiate the creation of a research world day, where all the actors in research could come together to present their findings and discuss new objectives for the future. In conclusion, should all the parties involved keep to their resolutions, the hope is high that this time around, they will be able to learn from the past and be more prepared to face the emergence and spread of resistance to new antimalarial therapies ( ACTs) in order to avoid or slow down to its minimum the development of resistance, so it does not suffer the fate of chloroquine or the likes.