Tropical Health Matters

World AIDS Day coming up on Sunday 1 December 2013 is not just a time to think about progress and challenges of one infectious disease, but the interaction between HIV and other infections, especially Malaria.  Adu-Gyasi and colleagues express the relationship well in their article on malaria among HIV patients in Ghana: “Malaria is associated with an increase in HIV viral load and a fall in CD4-cell count. Conversely, HIV infection disrupts the acquired immune responses to malaria and the efficacy of antimalarial drugs.” Recent research provides continued insight that we must look at the two diseases as a joint problem in malaria endemic regions.

Research was conducted on mice that were infected with P. chabaudi malaria. The mice showed increased gut and genital mucosal T cell immune activation and HIV co-receptor expression. The implication of the findings was that malaria infection might enhance the sexual acquisition of HIV in humans, and the authors recommended further research to learn more.

In another study researchers looked at Malaria and HIV co-infection and their effect on haemoglobin levels from three health-care institutions in Lagos, Nigeria. The data showed that the total number of malaria infected patients were significantly higher in HIV sero-positive patients 47.7% (31/65) when compared with their HIV sero-negative counterparts 25.8% (262/1015) P = 0.047.  Not only was there a higher prevalence of malaria in HIV infected patients but also patients co-infected with malaria and HIV were more likely to be anaemic.

Both HIV and malaria in pregnancy present serious problems. Another recent study looked at Cotrimoxazole (CTX) prophylaxis versus mefloquine (MQ) intermittent preventive treatment (IPT) to prevent malaria in HIV-infected pregnant women. The study concluded that, “CTX alone provided adequate protection against malaria in HIV-infected pregnant women, although MQ-IPTp showed higher efficacy against placental infection. Although more frequently associated with dizziness and vomiting, MQ-IPTp may be an effective alternative given concerns about parasite resistance to CTX.”

Concern about malaria and HIV in pregnancy also focuses on the child. Research examined malaria diagnosis in pregnancy in relation with early perinatal mother-to-child transmission (MTCT) of HIV.   The authors reported that “HIV MTCT risk increased by 29% (95% CI 4-58%) per MIP episode. Infants of women with at least two vs. no MIP diagnoses were 2.1 times more likely to be HIV infected by 6 weeks old (95% CI 1.31-3.45).”

Finally since concurrent experience of both malaria and HIV infections means taking multiple drugs, researchers have also looked at the potential challenges of drug interaction. “An extensive literature search produced eight articles detailing n = 44 individual pharmacokinetic interactions.”  While various HIV medications either increased or decreased the exposure to malaria drug components including lumefantrine and artemisinin, artemether-lumefantrine or artesunate combinations generally had little effect on the pharmacokinetics of HIV-antivirals (with two exceptions).

It is difficult to say which disease is closer to reaching elimination goals, but unless both are understood from their mutual impacts on transmission and treatment of the other, both will continue to elude control efforts.

During his talk in the final sessions of the MIM2013 6th Pan African Malaria Conference Dr. Olumide Ogundahunsi of WHO/TDR Geneva, highlighted four people who have demonstrated the multiplier effects of MIM research grants. Below are Dr. Ogundahunsi’s remarks.

In 1999, Lizette Koekemoer obtained her PhD from Witts.  Her first independent research grant was in 2003 and between 2004 and 2007 she was supported by MIM to study insecticide resistance in Anopheles arabiensis in southern Africa. She subsequently receieved funding from the national and international agencies to support her work on insecticide resistance mechanisms and novel control interventions.  She now heads the  Vector Control Reference Laboratory (VERL), National Institute For Communicable Diseases (NIED) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa

Sam Awolola obtained his PhD from the University of Ibadan in 1997 and received a grant to support his research on insecticide resistance of the malaria vector mosquitoes in Nigeria from MIM/TDR in 2003 after his post doc in South Africa. He subsequently received research grants from the welcome trust, European Commission and several other agencies.  He is currently the Deputy Director (research), Coordinator Malaria Research Program at the Nigerian Institute for Medical Research and chairs the indoor residual spraying subcommittee of the National Malaria Elimination Program In Nigeria.

Eric Achidi obtained his PhD in 1994 at Ibadan, Nigeria.  He was supported by MIM & TDR from 1998 to 2009 and over time has successfully competed for and received grants from WT, EU, FNIH.  He is presently the Vice Dean Faculty of Science at the University of Buea Cameroon … an institution that did not feature in the 3 publications per year list of the 1999 WT report.

Jane Chuma is one of the more recent recipients of capacity building support from MIM.  She obtained her PhD in 2006 from the University of Cape Town and received MIM support about the same time to study access to effective malaria treatment and prevention among the poorest groups in Kenya. She is now a researcher at the KEMRI-Wellcome Trust Research Programme where she is working on health financing for universal health coverage with funding from the Wellcome Trust and DfID. She supports the health financing task group in her country, helped initiate the establishment of a masters in health economics and policy at University of Nairobi and supports researchers in various countries in their work on health systems and health financing.

These are among the 90 plus MIM alumni, the vast majority of whom have remained in Africa and resisted the pressures of brain drain.  Our congratulations go to MIM-TDR with hopes that other agencies can step up and match this track record.

Olumide Ogundahunsi, of WHO/TDR Geneva, Switzerland provided a look back and toward the future of the Multilateral Initiative for Malaria (MIM) during one of the final plenary sessions at the MIM2013 6th Pan-African Malaria Conference in Durban.  Excerpts from his talk and slides are presented below…

Twenty years ago, we were asleep, malaria elimination was a dream, and the reality was a nightmare.  After the serial failures of the malaria eradication campaign in Africa, malaria control was barely moving along. But today we are wide awake, it is not yet “uhuru” as far as malaria goes but we are making gains having learnt the importance of combined interventions, we are applying them with success in a number of places.

However, there is still some distance to go in this war and many battles ahead.  To quote one of the plenary speakers during this conference, “the fight against malaria can only be won by well-trained people” (Dr Robert Newman).  …..

• People who have the necessary capacity to optimise the available tools and develop new ones.
• People who are embedded in the endemic countries
• People who know and understand the contexts in which the tools and interventions will be deployed.
• Communities empowered to implement and sustain interventions

The issue I would like to ponder in the next half hour is how we ensure that we have enough of these people to do the job!

The last time we were in Durban (as the MIM), the Welcome Trust, the MIM secretariat at that time, had just published a comprehensive report on malaria research capacity in Africa.  The report included data on for example the number of African institutions publishing more than 10 malaria related papers in the 3 years preceding the report – a mere 15 in the whole continent! This has changed significantly in the past 14 years to 38 Institutions.

Fifteen years ago only a handful of agencies and programs were interested in research capacity strengthening and there were even those who considered capacity building poor investments…..the situation has of course changed since and the members of my generation – the so called F2 generation who were either graduate students or post docs at that time maturing as

• Established researchers in reputable and highly successful institutions
• Working in Africa and meeting the challenges of working in a challenging environment
• Highly motivated scientists recognised by their peers and the international scientific community
• Contributing to research and control of malaria in their countries and the continent

 Of the 90 plus researchers in the F2 generation only 4 are no longer working in Africa.  They remain committed and well recognized experts in their fields.

There are also several institutions that have evolved in the past 14 years because of support for RCS…. Noguchi Memorial Institute or medical research in Ghana and the health research facilities in Kitampo, Bagamoyo, Centre Muraz Bobo Diolasso and the Centre Nationale de Recherche et de Formation Paludisme (CNRFP) in Ouagadougou.   CNRFP received the first grant in 1999 (slide 11) to study the relationship between malaria transmission intensity and clinical malaria, immune response and plasmodic index. The institution has since grown from a modest staff of six in 1999 to 36 currently.

It has acquired well established capacities for operational / implementation research, clinical trials and studies on vector management (slide 113, and funding from several international partners.

These stories illustrate how capacity is being built in Africa not only by WHO/TDR and the MIM but also MCDC, the WT, EDCTP/EC, the NIH, BMGF and SIDA/SAREC among others.

Is this enough? And can we rest content on the success and contributions of the current generation of African malaria researchers?  Is the capacity adequate?

It will be naive to look at Africa as a single entity as is often done.  The capacity (human resource and infrastructure) for research and control against malaria does not match the burden or the scope of the battle.  There are still places where there are:

• Limited human resources
• Lack of infrastructure
• Funding disparity
• Limited access to technology
• Limited interactions between the research and control communities

The last of these….. “limited interactions between research and control communities“ in particular pose a significant barrier to effective deployment of interventions and strategies.

It is not enough to prove that a strategy or an intervention works (often in a controlled setting).  In the real life context, there are multiple factors ranging from the quality and structure of the health system, to culture, the political, and the socio economic  that impact on our ability to effectively implement or scale up for impact.

The next generation of malaria researchers in Africa must be able to better address this gap if we must extend the frontiers of malaria elimination and shrink the malaria map further.

I can say most of the current generation (my generation) stood on the shoulders of an older generation of African scientists and their collaborators in other continents (someone referred to them as baobab trees a few days ago), the exposure, training, mentorship and the opportunities they created following Dakar have helped us along……

However when you consider the proportion of Africans speaking at the plenaries during this conference and the number of young scientists and graduate students attending as a whole, I think we have still have a long way to go!

How can we foster the next generation and further strengthen capacity for malaria research in Africa – within the unique context of each country.

As I conclude I want to reflect on the African perspective of training needs and solutions. 14 years ago in identifying enhancers of developing and maintaining a research career in tropical medicine in Africa, we put forward the following:

• Research funding
• Research infrastructure
• Communications
• Better salaries and career development
• High quality training

To this I could add one more …. Mentoring

These issues remain highly relevant and must be continuously addressed if we are to sustain and indeed improve malaria research capacity in Africa.

Since the creation of MIM, we have seen an increase in research funding in Africa, emergence of centers of excellence, better communication and collaboration to a large extent driven by the global it boom. Better salaries, career development and high quality training!

However in general, funding for research including operations research (and capacity building) in Africa is to a large extent dependent on external funding.

National efforts at capacity building are to a large extent limited to statutory funding for graduate, postgraduate and diploma programmes. Beyond this there is little funding for post-doctoral research training, operational research within programs or innovative product research and development.

In the more than almost one and a half decade since the global community committed to Roll Back Malaria, we have had malaria initiatives from presidents but the human resources to under pin these efforts remain inadequate. We have to do better in capacity building so that 10 years down the road, there is a new generation of well-trained people embedded in the endemic countries with the capacity to optimise the tools and develop new ones if necessary.  Now is the time ……….

• To lobby and convince African political leaders and governments to invest in research and capacity building
• To convince the African billionaires who feature in Forbes list to invest in African scientists
• And to the senior, successful and established African scientists and managers…. It is time to invest in younger talent as mentors.

In 1997, MIM was in the vanguard of an effort to address the issues of

• Research funding
• Research infrastructure
• Communications
• Better salaries and career development
• High quality training

Bringing these issues to the attention of the international community and in some cases providing inputs to address them is still an important part of the MIM agenda.

The MIM is even more important now as an advocate for research and capacity building in Africa. WHO/TDR will work with the MIM secretariat to conduct an independent review of the MIM for continued relevance and contribution to the fight against malaria.

The Special Programme for Research and Training in Tropical Diseases (TDR – Unicef/UNDP/World Bank/WHO) seized the opportunity of the Multilateral Initiative on Malaria (MIM) 6th Pan-African Conference on Malaria in Durban 6?11 October to touch base with its ‘alumni’ who have received research and training grants over the almost 40 years since its inception.  A workshop was held discuss a new TDR alumni network platform and seek input on ideas for what that platform might look like and accomplish.

TDR has trained and supported thousands of researchers across the globe. We would like to assess how we can continue to support our alumni and their connections to people and institutions. This is a major new initiative that TDR will develop in 2014, and it wanted people who are familiar with TDR to provide feedback to initial plans for a new platform that will allow for better tracking of career progression and promotion, and to get ideas on how to increase opportunities for collaborations with other researchers and funders.

The idea of an alumni network was received enthusiastically by the more than 40 participants at the session, many of whom attested to the crucial role TDR played in their scientific careers either by supporting their doctoral studies or providing them grants that resulted in published work that help promote their careers.

Participants discussed various web based options where alumni profiles could be maintained and opportunities to share skills and solicit collaboration on research and training activities.  Other suggestions included an alumni newsletter and regular alumni meetings to coincide with international conferences that address the diseases of poverty.

TDR Director John Reeder said the organization was enthusiastic about receiving alumni input.  This participation will hopefully reinvigorate an organization that had been in a quiet transition over the past few years. The network will provide a good opportunity to learn how TDR investment in individuals and small teams has spawned further discoveries and disease control innovations.

On a personal basis, I can say that TDR grants to our team at the University of Ibadan beginning in 1981, helped us refine the concepts and capacities of volunteer community health workers (CHW) in tropical disease control including a contribution to guinea worm elimination in Nigeria, dissemination of pre-packaged anti-malarial drugs and refining the concept of the community directed distributor of ivermectin for onchocerciasis control and elimination.

These CHW principles have been worked into a new offering on Coursera, “Training and Learning Programs for Community Health Workers,” so that others can benefit from the lessons engendered through TDR support. Hopefully other alumni can use the network to share the benefits they have gained from TDR.

The World Health Report 2013 entitled Research for Universal Health Coverage has been released. Since universal coverage has been a central Roll Back Malaria target since 2009, we have included below some of the mentions of studies and activities around malaria service provision and scaling-up.

The case for investing in research is made, in part, by demonstrating that scientific investigations really do produce results that can be translated into accessible and affordable health services that provide benefits for health… In one (example) a systematic review of survey data from 22 African countries showed how the use of insecticide-treated mosquito nets was associated with fewer malaria infections and lower mortality in young children. This evidence underlines the value of scaling up and maintaining coverage of insecticide-treated nets in malaria-endemic areas. (page xiv)

(Environmental risk factors) also contribute to the transmission of vector-borne diseases: malaria is associated with policies and practices on land use, deforestation, water resource management, settlement siting and house design. (Page 41).

By killing or repelling mosquitoes, insecticide-treated bed nets protect the individuals sleeping under them from malaria. By killing mosquitoes, they should also reduce malaria transmission in the community. Randomized controlled trials conducted in sub-Saharan Africa in a range of malaria endemic settings have provided robust evidence of the efficacy of ITNs in reducing malaria parasite prevalence and incidence and all-cause child mortality. Such trials showed that ITNs can reduce Plasmodium falciparum prevalence among children younger than five years of age by 13% and malaria deaths by 18%. (page 61)

(More research is needed because) In contrast with the findings of controlled trials, ITNs may be less effective in routine use because the insecticidal effect wears off, or nets may be used inappropriately or become damaged. The impact of ITNs, as used routinely, on malaria and childhood mortality is therefore uncertain.  (page 62)

As we can see from the World Health Report, malaria research has made a major contribution to our understanding of factors and effects of scaling up programs to try to achieve universal coverage.  As WHO recommends, more funding for health service coverage is needed, and malaria countries countries themselves need to contribute their own share in supporting their own research institutions.

Tuberculosis is one of the big three receiving Global Fund support, and like HIV and malaria control efforts, the emphasis is on multiple interventions to ensure ultimate success. Compared to the other diseases, TB’s interventions have been mainly limited to immunization and directly observed treatment. Both of these interventions have recently met some major challenges that have also plagued the other big diseases.

Roger Bate and colleagues, who have focused on the problems of fake and substandard malaria drugs have turned their attention to TB. (see http://masetto.ingentaselect.co.uk/fstemp/a5829970064042ab6ec12023d514ef4f.pdf ). Their investigation at pharmacies in 19 Asian and African countries found around 9% of TB drugs were substandard/poor quality. The rate of fake medicines was 16% in Africa and 10% in Asia.

Governments in these countries were encouraged to give these issues greater attention including better regulation and collaboration with international policing efforts.

The need for new vaccines is a necessary development to maintain a strong disease control arsenal. For TB, “A new vaccine, modified Vaccinia Ankara virus expressing antigen 85A (MVA85A), was designed to enhance the protective efficacy of BCG.” (as reported in The Lancet http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960177-4/abstract )

As the BBC report on this study pointed out, “BCG is only partially effective against the bacterium that causes TB, which is why several international teams are working on new vaccines.” (see BBC at http://www.bbc.co.uk/news/health-21302518 )

While the new vaccine “… was well tolerated and induced modest cell-mediated immune responses. Reasons for the absence of MVA85A efficacy against tuberculosis or M tuberculosis infection in infants need exploration.” Fortunately research on other vaccine candidates is underway.

Continued control and eventual elimination of malaria and TB will require research that is both basic (vaccines) and applied (drug quality) in order to develop, maintain and implement effective strategies. Disease research budgets should not be compromised in the ever changing world of pathogen/parasite evolution.

The Nigerian Institute for Medical Research (NIMR) in Yaba, Lagos has been a major player in generating knowledge about malaria for national and international policy makers. Just a few days ago, one of its distinguished researchers Dr. P.U. Agomo (BSc Hons, MSc, PhD, AIMLS) retired after 32 years of service. He had attained the post of Director  of Research  (Biochemistry  and Nutrition) at NIMR. Below is the citation provided by NIMR on the occasion of his send-off party, 13 August 2012.

Dr Philip Agomo was born in August, 1947. He graduated from Greenwich University, London,  UK with  a BSc (Hons)  in  Biochemistry  (1973),  MSc in Applied Immunology from Brunel University, Uxbridge, Middlesex, England, UK (1977) and PhD from University of London, UK (1980).

Dr Agomo joined NIMR in 1980 as a research Fellow II and rose through the ranks of leadership to become the Director of Research (Biochemistry and Nutrition)  in 2008 and acting Director General of NIMR  from  July 2008 to May, 2010. Dr Agomo has also served the World health Organization (WHO) as an adviser on Antimalarial drug packaging for home management of malaria, appropriateness of childhood fever treatment in Africa, Health Sector Reform for Capacity Strengthening  and Malaria control in Africa and implementation  of community based management of Acute respiratory  infection  (ARI)  in Africa.

At the regional level, Dr. Agomo served West African Health Organization (WAHO) as an adviser on Health Research System Strengthening in the West African region. He also served as the Chairman of the Monitoring and evaluation sub-Committee of the National Malaria Control Committee (transformed  to NMCP in 2005) from 2001 to date.

Dr Agomo has also participated in many malaria control programmes at international,  regional, national and state levels as a Principal Investigator winning many  academic awards and research grants. Notable among these is the placement of NIMR as a training sub-recipient in the implementation  of global fund round 4 phase 2 (2008)  and round 8 (2010),  funded with about N150m Naira.

Dr. Agomo is well recognized not only for scholastic, administrative  and leadership qualities but also as a mentor of students and junior research scientists at NIMR, in Nigerian universities and outside the country. He has produced more than 10 PhD holders as a co-supervisor  in Malaria research (Pharmacokinetics,  Drug Resistance and Immunology),  Nutritional  Biochemistry  and Toxicology.  Dr. Agomo has to his credit over 80 scientific publications in peer-reviewed journals. He is happily married and blessed with two children. He is also a grandfather. 

Below are a few of Dr Agomo’s malaria-related publications that span his 30-year career:

• Prevalence of malaria in pregnant women in Lagos, South-West Nigeria. Agomo CO, Oyibo WA, Anorlu RI, Agomo PU. Korean J Parasitol. 2009 Jun;47(2):179-83. Epub 2009 May 27.
• Efficacy, safety and tolerability of artesunate-mefloquine in the treatment of uncomplicated Plasmodium falciparum malaria in four geographic zones of Nigeria. Agomo PU, Meremikwu MM, Watila IM, Omalu IJ, Odey FA, Oguche S, Ezeiru VI, Aina OO. Malar J. 2008 Sep 9;7:172.
• Treatment of childhood fevers and other illnesses in three rural Nigerian communities. Salako LA, Brieger WR, Afolabi BM, Umeh RE, Agomo PU, Asa S, Adeneye AK, Nwankwo BO, Akinlade CO. J Trop Pediatr. 2001 Aug;47(4):230-8.
• Analysis of human antibodies to erythrocyte binding antigen 175 of Plasmodium falciparum. Okenu DM, Riley EM, Bickle QD, Agomo PU, Barbosa A, Daugherty JR, Lanar DE, Conway DJ. Infect Immun. 2000 Oct;68(10):5559-66.
• Effect of chlorpheniramine on the pharmacokinetics of and response to chloroquine of Nigerian children with falciparum malaria. Okonkwo CA, Coker HA, Agomo PU, Ogunbanwo JA, Mafe AG, Agomo CO, Afolabi BM. Trans R Soc Trop Med Hyg. 1999 May-Jun;93(3):306-11.
• “Antimalarial” medicinal plants and their impact on cell populations in various organs of mice. Agomo PU, Idigo JC, Afolabi BM. Afr J Med Med Sci. 1992 Dec;21(2):39-46.
• Cell-mediated immunity in the liver of mice vaccinated against malaria. Playfair JH, De Souza JB, Dockrell HM, Agomo PU, Taverne J. Nature. 1979 Dec 13;282(5740):731-4.
• Development and suppression of a population of late-adhering macrophages in mouse malaria. Lelchuk R, Taverne J, Agomo PU, Playfair JH. Parasite Immunol. 1979 Spring;1(1):61-78.

This morning’s Washington Post featured a story concerning another setback in HIV/AIDS prevention research. The article stated that, “The abrupt closure last week of one part of a complicated study called VOICE marked the third time in eight months that anti­retroviral drugs did not prevent infection in those assigned to use them.” Ironically, the interventions had proven effective in smaller scale trials.  What happened during scale up?

The two research interventions focused on either having women insert a vaginal gel daily or people taking pills. One explanation offered for the failure the second time around was as follows:

The answers may lie in subtle differences between the groups being studied and the designs of the experiments. For example, the volunteers in Partners PrEP (pre-exposure prophylaxis study) were long-term couples in which one person was infected and the other not. It’s possible they may have been more motivated to take the pills every day. In CAPRISA (the South African PrEP study), the women inserted the vaginal gel before and after sexual intercourse rather than every day — a targeted approach that may have helped them stick to the program.

Such differences in the social and behavioral context of research make all the difference – basic research on drug effectiveness cannot be divorced from the people who receive the medications. The Post contacted experts who offered the following opinions about why there were problems.

• The daily regimen just probably was not acceptable; if the gel were being used according to instructions some differences between groups should have emerged.
• Other studies of vaginal microb­icides and pre-exposure prophylaxis have shown that few people use prevention tools as regularly as they say they do, but the more “adherent” people are, the more protection they get.
• What we have to face up to is that everything in HIV prevention is based in human behavior.

The article concluded by saying, “What seems clear is that this strategy, once viewed as the easiest and most certain, is going to require a lot of fine-tuning even if it works.”

With malaria interventions, similar lessons apply. ACTs do not protect is people do not adhere to the 3-day regimen. LLINs do not protect if people use them to cover their vegetable gardens. IPTp is not effective unless pregnant women attend antenatal care regularly. Rapid diagnostic tests are wasted if health workers do not believe in their efficacy.

Often we wait until problems of non- or inappropriate utilization of health interventions occur before we start looking at social and behavioral factors. The Post quoted one epidemiologist who said, “People are upset. It’s a big head-scratcher as to why it didn’t work.” Researchers should be embarrassed to admit such, as this means they did not do adequate formative research in advance to understand the social and cultural context into which they were introducing their innovations.

Certainly similar mistakes have been made in malaria research and intervention, but now with international donor funding severely threatened, we cannot waste resources pushing interventions that are not socially and culturally acceptable.

Gawrie Galappaththy guided a session at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop that helped participants summarize their group work on training and research to support community participation in malaria elimination.  Her report follows:

All the participants were agreed and thought that following training areas are necessary for effective community engagement for malaria elimination.  Thoughts about training included key topics and target groups as seen below.

• Advocacy – Advocacy  is needed for all level including central, district, village level for all the category of staff
• Partnership with other sectors- specially with the public sector as more than 50% of patients in most of the countries seek treatment from the public sector
• Skills on communication methods – As most of the health personnel is not very much familiar with communication, methods it is important to train all the trainers on communication methods eg -COMBI, materials, participatory approach)
• Resource mobilization- funds as well as personals
• Integration with other diseases – community engagement as an integral part of the health (health package)
• Training for community – training of community on every aspects of malaria
• Strategy developments – most of the malaria programmes in their strategic plans not mentions the involvement of community in malaria elimination. It is important to include this aspect along with key activities
• Skills on Monitoring & Evaluation – most of the countries engaged community for malaria control but lack M&E component. It is important to include M&E as an integral part of the elimination statergy
• Empowerment of community for sustainability of community engagement in malaria elimination

Many research areas were identified by the participants, but need to priority areas depending on funds availability.  Examples of priority research issues included …

• Cost effectiveness of engagement of community in malaria elimination
• Improvement of drug compliance specially among migrant workers
• Case studies or documentation of success stories
• Promote treatment seeking behaviour specially in   malaria elimination countries
• KAP studies on malaria especially since perceptions may change as we progress toward elimination
• Role of community in malaria elimination
• Effectiveness of village malaria posts/brigade in malaria elimination
• Role of NGOs/FBOs in malaria using community engagement
• Development and testing of Training modules
• Research on new mechanisms of community  engagement for mobile population
• Understand community structure and to identify the mechanism to sustain motivationAchieving synchronous cross boarder community engagement for malaria elimination

Of particular interest in the region are the training and research needs to identify and test strategies for community engagement between countries – cross-border areas present a special challenge in terms of mobile populations and malaria medicine resistance. APMEN therefore, has to play a major role in advocacy as it is important to increase awareness among politicians, decision makers regarding cross border problems between countries. APMEN can raise a voice in international bodies such as SAARC, ASEAN, BIMSTEC etc.

Regular meetings in cross-border areas are essential at district/state level between countries eg  Bhutan and ASSAM, Bhutan and West Bengal.  There is need to address the issue of communication methods between countries taking into consideration ethnicity, language, cultural background etc

Priority Research and training needs for cross-border areas include descriptive studies to understand the migrant pattern, behavior, and risk groups. We also require needs assessment studies including assessments of existing facilities among border populations.

On the final day of the workshop, participants refined and prioritized these research and training topics for follow-up action back home.

John Costa of Ashdin Publishing has written to let us know about a new open access journal on malaria: Malaria Chemotherapy, Control & Elimination.

John Costa explains that, the new journal, MCCE, has been recently launched by Ashdin Publishing. The journal aims to bridge basic and applied malaria research in tropical and other settings.

MCCE will provide contributors with a forum for publication of research findings, in the form of basic science, clinical studies, case reports, and focused or general reviews of science or policy. MCCE is published using an open access publication model, meaning that all interested readers will be able to access  the journal freely online without the need for a subscription.

Although Editorial Board positions have not yet all been been filled, there is a significant contribution from the London School of Tropical Medicine and Hygiene (LSHTM) and alumni as well as other distinguished workers. The publishers hope to see the journal accepted as an essential forum in the coming years.

Of note, the journal will be affiliated with the Malaria Center at the London School of Hygiene and Tropical Medicine, which houses the largest number of malaria researchers, students and support staff in Europe. The Center is unique in its size and breadth and draws together the diverse research and teaching activities carried out at the School.