P 021403Z MAR 09
FM AMEMBASSY ANTANANARIVO
TO SECSTATE WASHDC PRIORITY 2157
INFO AFRICAN UNION COLLECTIVE PRIORITY
AMEMBASSY BEIJING PRIORITY 
CDC ATLANTA GA PRIORITY

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