Strategy
To summarise in brief, the strategy of the IVCC is to identify opportunities for the development of new products, strategies and tools for improved vector control, and to enable, and support those projects by the development of partnerships that bring together the complete set of resources ( technical, enabling and financial) to bring those products to market, or the strategies into broad dissemination.

Current Status of Vector Control and the Public Health Pesticide Product Market
 Mosquito vector control is capable of spectacular results.  The malaria eradication campaigns of the mid 1900’s eliminated malaria in much of the world.  It was driven out of the USA, most of Europe, Latin America and Asia, and even in Sub-Saharan Africa the disease burden was reduced substantially.  The eradication campaigns were discontinued for a variety of reasons, including concerns about drug and insecticide resistance and problems with sustainability. 

Vector control, as conducted in the 1960’s, relied on intensive, short-term efforts, without a long term vision or strategy for maintenance.  Over the last two decades there has been a shift, in Africa, away from the original paradigm of indoor residual spraying (IRS) of insecticides towards large scale distribution of insecticide treated bednets (ITNs). Early large scale experimental trials of ITNs demonstrated that this intervention was able dramatically to reduce malaria morbidity and mortality. This resulted in:

ITN production and procurement issues, the logistics of distribution and availability of funding meant that the 2005 target was not met, although millions of ITNs were distributed in Africa and ITN production capacity internationally was increased to met demand.

More recently innovations such as the Global Fund for Aids, TB and Malaria (GFATM) and the Presidential Malaria Initiative (PMI) have increased the funding available for large scale operational malaria control programmes in Africa for both ITNs and IRS. Technological advances have also brought long lasting wash resistant ITNs (LLINs) to the market which have an insecticide treatment that lasts for the useful life of the net, avoiding the logistical problems associated with regular net re-treatment with insecticide. 

A major remaining issue with ITNs is the current recommendation of only one insecticide class, the pyrethroids, for net impregnation, leaving the intervention vulnerable to failure if operational levels of resistance are selected in the mosquitoes. While insecticide choice is wider for IRS, only four classes of insecticide are registered for IRS use and resistance is already present to all classes in some mosquito populations.  

 


Both IRS and ITN interventions could be deployed in a more cost effective and sustainable format if malaria incidence and /or prevalence and mosquito densities and insecticide resistance status could be routinely monitored and the data used to inform decisions on the timing and geographical placement of treatments. Technological and capacity issues currently preclude effective monitoring in most national control operations.

 

Dengue is spreading rapidly in many parts of the world.  The strategy of mosquito larval source reduction and space spraying to eliminate dengue epidemics has been largely ineffective and not sustainable.  It is clear that we need to respond to potential dengue outbreaks more rapidly and efficiently than is possible at present. New methodologies are needed to cost effectively monitor the likely outbreak of dengue and more rapid and effective responses are then needed if the impact of dengue in disease endemic settings is to be reduced and future epidemics are to be eliminated.  In disease endemic areas of the world the integrated approaches and tools developed by the IVCC will be key to sustaining the new wave of international and national disease endemic country enthusiasm for effective malaria and dengue control.

Economics and Business Issues of PHP Development and Introduction
Insecticides for mosquito control are in short supply.  Existing products are constrained by cost, environmental and human toxicity and resistance.  Products developed for the agrochemical market in the 1960s and 1970s (organophosphates, carbamates and pyrethroids) were reformulated for use as PHPs.  However, a move away from contact toxicity and persistence, for new agrochemical products in the 1980s, has meant that many modern agricultural insecticides are not so easily re-purposed and no new products have been registered for the mainstream adulticide malaria PHP applications since the mid 1980s. 

Industrial players who have the capability to deliver PHPs, but are not doing so, report the following reasons for the market failure.   

Theory of Change /  Overcoming Market Failure
Successful interventions in failing marketplaces are often characterised by the combined effect of decreasing the supply side barriers and increasing the demand side pull.  This is exemplified by the Orphan Drugs Act in the US where a mixture of supply side tax breaks and demand side incentives (extended exclusivity etc) have successfully recovered some 250 otherwise uneconomic drugs.

The reasons described above for the market failure also provide the indicators for the reduction of supply side barriers including:-

 

These are the type of intervention that the IVCC can productively bring to the supply side of the equation.

Intervention on the demand side of the equation is beyond the scope of the IVCC.  However, many other organisations are active in this regard (GFATM, PMI, Oxfam etc).  Optimal performance in overcoming the market failure will be achieved by choreography of the supply and demand side interventions

 

The Role of the IVCC - what do we need to do?
The IVCC has the funding, the authority and increasingly the experience to play a key role as a champion for the development of new public health insecticides and better vector control information systems.  In undertaking this programme the IVCC needs a robust evidence-based format to define the scope of its product portfolio and select the best candidate products to fit the needs of the user community in a timely manner.  This format is derived at three levels :-

The Mission Statement which provides an enduring compass to the IVCC.

The Corporate Objectives that provide the measurable outcomes required to give substance to the mission.

And the Roadmap and Portfolio which are an outline plan of the classes of product development and activity milestones which constitute delivery of the objectives, and the portfolio of projects that deliver those outcomes.

Key Issues
The key issues that the IVCC needs to address can be described as:-

  1. The need to bring new active ingredients to bear on the challenge of vector control to overcome the developing issue of resistance to current public health insecticides.  This can be achieved in the short term by repurposing of known insecticides from the agrochemical industry.  However, in the longer term it is anticipated that the entirely novel AIs will be needed.
  1. In addition the vector control community will need new strategies or paradigms and new information systems and tools to manage the novel AIs in a sustainable way so as to optimise their use in the field and prevent their loss through the development of resistance.  

 

As development of the new AIs and Information systems progresses they must be first inform each other of their developing capability and requirements and finally be integrated into evidence based Vector Control Systems

 

 

Corporate Objectives
Within our current 5 year strategic plan the IVCC needs to deliver the following outcomes

  1. To establish a portfolio of new pesticide active ingredient and formulation products, which when brought into use in the PHP marketplace are sufficient to enable rational and effective product stewardship programmes and reduce by 25% the cost of application of IRS programmes.
  1. To develop a set of malaria and dengue control information systems, analytical tools and strategies that will enable, in conjunction with the new public health products an effective disease control and resistance management programmes.
  1. Contribute to, and influence, the global debate on innovative vector control strategies and best practice. 
  1. Develop an organisation that is capable of delivering the ongoing Mission Statement of the IVCC, with an evidence-based roadmap of future needs and a strategy for their resolution. 

The IVCC Portfolio
Turning the objectives into development programmes that can deliver the required outcomes leads to four synergistic classes of project that form the portfolio:-

 

Formulation and repurposing.  This group of projects addresses the short term opportunity to repurpose known agricultural insecticides into formulations suitable for deployment as public health pesticides.  Key targets for these are the capacity for resistance management by the introduction of new AIs and reduction in the cost of implementation arising from increased residuality and hence reduced cost  of application.

Novel Sustainable AIs.  This part of the portfolio addresses the introduction of entirely new chemicals into the Vector Control market.  These projects are substantially longer and more costly than repurposing but provide the opportunity to introduce agents for which there is no current pool of resistance that will lead to a sustainable pesticide armoury.  Key product targets here are safety, efficacy and cost. 

Information Systems and Tools.  Information systems form an increasingly important part disease control programmes and these projects aim to provide the strategy and best practice for the design implementation and operation of such information systems.  In addition to the information system we are developing a series of tools which will provide some of the key data about vector populations that are required for the operation of the information systems.

New Paradigms in Public Health.  Many vector control interventions are well understood and the conditions under which they are effective well documented.  However, future vector control products will call for novel interventions for which the effectiveness is not established.  (For example Insecticide treated curtains or consumer products aimed at vector control).  These projects aim to establish the effectiveness of these new paradigms in vector control.
 
Details of the current status of the portfolio and opportunities to work with the IVCC to complete the portfolio may be found in current portfolio status

Resources, Structure and Processes - how are we going to do it?
In order for the IVCC to successfully deliver its objectives it must bring to the vector control industry the key resources whose absence has caused the market failures described above.
Critical Success Requirements of the IVCC are:-

Skills / Know-how
The IVCC must contain the key skills to identify, nurture and deliver the Projects and Products that will fulfil the key objectives.  Those skills consist of :-

Enabling resources

Financial Resources

 Strategic Options - looking forward to the future
Long term disease control programmes will require that the insecticide products that we develop are deployed through a system of good product stewardship in order to maintain the safety and effectiveness of the products.  One aspect of this stewardship lies in the requirement for resistance management programmes. 

In the very short term, resistance management can be achieved by the introduction of alternative insecticides for use in bi-treated products or rotations of known insecticide classes in IRS where no immediate cross-resistance is observed in the target insect populations.  However, it is clear that as long as the modes of action are similar and cross-resistance exists, the replacement of the existing resisted insecticides with these alternatives will simply induce the evolution of insects resistant to the new products.  

A long term resistance management programme will require a suite of three insecticide products with different modes of action that do not exhibit cross-resistance and none of which has established resistance in the target population of insects.  This requires the development of novel insecticides, an activity that will cost some $200-300M for each new product and take a period of 10-12 years.   

The IVCC is currently engaged in planning for a longer term programme than the initial 5 year, $50m grant from the BMGF that would be capable of delivering these broader outcomes.