7 September 2012

Africa: Eradicating Malaria Possible but Needs Efforts and Funds

Photo: Benoit Matsha-Carpentier/IFRC
A Red Cross bed net distribution team checks households to record the number of people in each household and the number of sleeping places (file photo).

Washington, DC — The last decade has seen a successful global effort to reduce the toll of malaria - a deadly, mosquito-borne infectious disease. In the Africa region, according to the World Health Organization (WHO), malaria deaths have been cut by 33 percent in the past decade. Scaling up anti-malaria efforts has saved 800,000 to a million African lives, most of them in the last six years and most of them children.

In an interview with AllAfrica last year, malaria expert Dr. Carlos (Kent) Campbell, said that funds spent combating malaria have saved lives "at a level that exceeds virtually any other investment in global health that we have today, including vaccines".

But huge challenges remain. Malaria still kills some 800,000 people a year, over 90 percent of them in Africa. Nigeria, for example, has more malaria deaths than any other country.

And a new threat looms from resistance of the malaria parasite to Artemisinin, a substance derived from a Chinese herb and a key component of ACTs - Atremisinin-based combination therapies - considered the most effective treatment for malaria in areas where other drugs have already lost effectiveness, which includes Africa. So far the drug resistance has only been documented in southeast Asia, and late last month, regional health officials met in Cambodia to plan a strategy for containing and addressing the problem.

In Arusha, Tanzania on Wednesday, the Geneva-based Roll Back Malaria partnership - "the global framework for coordinated action against malaria" - launched a new campaign to communicate anti-malaria efforts, with the aim of increasing malaria prevention and treatment. The strategic plan calls for increased advocacy at local, regional and global levels.

Last week, the South African government announced a potential malaria treatment it called "the discovery of a compound which will be the first ever clinical candidate researched on African soil as part of a modern pharmaceutical industry drug discovery programme", in collaboration with the Medicines for Malaria Venture (MMV).

In an interview, Dr. David Brandling-Bennett, deputy director of the malaria programme at the Bill & Melinda Gates Foundation, told AllAfrica that the encouraging progress to reduce and eventually eliminate malaria cannot continue without sustained attention and resources.

In the wake of documented progress against malaria, what are the most important frontiers in research and treatment?

The most important challenge is sustaining this effort: continuing to provide nets, making sure that people have access to drugs, that they use the available preventive measures.

In the current economic climate, there is no certainty that funds - from the international community, bilateral or multilateral donors, or even the countries themselves - will continue.

So that's the major challenge. That's a big focus of the malaria community, for example, the Roll Back Malaria partnership.

There are a number of scientific challenges. We always face the threat of resistance of the parasite to drugs, and we can continue to work on the development of new drugs.

We are also addressing very aggressively the threat of the spread of artemisinin resistance in southeast Asia - in Cambodia and eastern Mynamar. Efforts are underway to contain that and, if possible, eliminate it. We will do our best to prevent the spread of that resistance or the development of resistance elsewhere.

We also have a problem with resistance by the mosquito to the insecticides that are being used. That resistance, as we measure it, is kind of widespread but, fortunately, has had limited impact on our programs so far. We do need to find replacement insecticides to use, for example, on bed nets and for indoor residual spraying, but we also want to find alternative methods for controlling the mosquito population, so that - potentially - we don't have to rely on insecticides at all.

On that topic of new research, scientists at the University of Cape Town have been working on a new drug for malaria treatment, which has shown promise. What can you say about that?

Actually, we got a communication from the CEO of MMV, Dr. David Reddy, pointing out this development, which is very nice.

It looks promising, but of course it has a long way to go. It's an early development. It's got to go through all of the clinical trials, and of course many drugs unfortunately fail, either because they are not as efficacious or have toxicity that isn't detected early in the development.

Hopefully that won't happen with this drug. We are optimistic, but we really won't know until all the trials have been completed.

Should its initial promise be realized, what would be the significance?

Well, we always - we and others - continue to look for anti-malarials which hopefully will be more effective, simple to use, cheaper than the drugs we have. Current drugs require multiple doses, and they are relatively expensive, and it's hard to get the price down further than we have.

If this drug actually proves clinically effective in the development process and is a cheap, single-dose drug, that would be a significant development. But we don't know if that will be the case.

Is other research on similar drugs underway?

Yes, MMV has other drugs - some further along in the development process than others - but all of them still several years away from being available.

So, in the meantime, what do you see as the drivers for continued progress in the campaign against malaria?

I think it's a combination of things. The Roll Back Malaria partnership is actually devoting a lot of attention to this and to a major effort to try and keep the bilateral, multilateral organizations engaged - The Global Fund [link], for example, as well as the President's Malaria Initiative [link], the World Bank [link to malaria on WB site]. But we are also working with countries, too - encouraging them to increase their own domestic resources to malaria, when they can find ways to do that.

There seems to be a new global focus on malaria and maternal health, among sectors that often operate quite separately.

Yes, we have become aware that what we had hoped would be progress in preventing malaria in pregnancy has not been as good as we had expected.

There are various reasons for that. We were involved in the meeting arranged by the Maternal Health Task Force at Harvard [link to site], in Istanbul at the end of June, which looked at the various issues: why we were not getting prevention of malaria in pregnancy, and the consequences of that. [post and link to any pertinent reports coming out if that meeting]

There are follow up plans to that meeting, to have better, clearer guidelines and better coordination between global and national guidelines, to try and encourage more effective maternity care and neonatal (newborn) clinics, so that they provide both the nets that protect women from malaria and the drugs that can be given during pregnancy and prevent the effects of malaria in pregnancy.

We know that this has a very positive effect in preventing anemia in pregnancy, and in preventing low birth weight. And low birth weight has lots of consequences, including an association with higher neonatal and infant death rates, and it has long-term consequences.

So there is considerable benefit in preventing malaria during pregnancy.

We are hoping that by getting more attention, figuring out what are the barriers to more effective prevention and giving more attention to this - and actually bringing the maternal and child health communities and the malaria communities together - that we can make more progress in prevention than we have.

What are the existing barriers to effective treatment? Are stock-outs - when treatment facilities are out of needed drugs - an important one?

That is certainly one factor. One thing we are doing with the WHO - we'll start working with countries to simplify [treatment] guidelines and update guidelines and then work with countries so that their guidelines match with WHO guidelines for preventing malaria in pregnancy.

And then we'll work with countries to find out why they haven't had as much success with prevention, utilizing the experiences of countries which have had more success, like Zambia and Rwanda, for example. And certainly working with other countries - Tanzania, Uganda, possibly Kenya. We haven't actually started that work yet.

Ideas are being explored on how we can work with additional countries to help them scale up prevention measures much more effectively.

And for treatment - ACTs - as well?

ACTs will be used for treatment in the second and third trimester. These are not advised during the first trimester, because of potential adverse effect on the fetus.

I was thinking also about overall the lack of ACT availability...

Right. Well, there are a number of factors. A major factor has been cost. You have, I am sure, heard of the Affordable Medicine Facility for Malaria [link], which has been a pilot program of The Global Fund. That has undergone an evaluation now, and the Global Fund and the Roll Back Malaria partnership are in the process of deciding how this should be managed in the future.

As I said before, there are also efforts to find alternative drugs that are less expensive, although that will take time.

There are additional challenges. Drugs in many countries are available more through the private sector than the public sector. Ensuring that people have access to quality drugs, and that second line or inferior drugs, or even poor quality drugs, are not being used is important.

How do you view organized citizens' actions and the roll of non-governmental organizations (NGOs) and policy makers?

We consider them very important. As a matter of fact, we provide some modest support to the African Leaders Malaria Alliance (ALMA) and so we are well aware of the work they are doing.

We actually do a lot of funding and work in advocacy, which I consider a very broad term for encouraging all of the required work in malaria - including attention to policy and financing issues, as well as just advocating for a little more attention to malaria, and more resources for malaria.

Where do you see the most promising interventions over the next few years?

The interventions we have are highly effective. We need to continue those and ensure access to drugs. We need to ensure that people have, and use, bed nets, and that those nets are replaced. Replacing nets at the right time, when they are needed, in an efficient and cost effective way, is a challenge.

At the same time, we recognize that, as I have indicated, resistance is a threat, and that the current tools, particularly nets and indoor residual spraying, are not ideal. So we are working on developing alternative approaches.

One of the promising areas is the use of spatial repellents - mosquito coils, for example. It's looking like those may be effective in controlling malaria; we have very preliminary data on that.

But we want other things that are easier to use. That's a promising area of research. There are vector control approaches [which target them], which are being investigated. Again, those are early days, as they are for new drugs.

And, of course, work on drugs, find better drugs.

We continue to work intensively on malaria vaccines. The data continue to look promising but that [latest potential] vaccine is not going to be available until, we expect, 2015. Then we'll have to see where it would be most appropriate to use that vaccine.

We are continuing to work to achieve our ultimate goal of malaria eradication.

I think what has been most encouraging to me has been the way the malaria community has moved together during the last five to seven years - coming together in the Roll Back Malaria partnership. The current global malaria action plan focuses on 2015. The Roll Back Malaria partnership is already beginning to think about its next global malaria action plan.

So that is both an opportunity and a challenge, and we are looking forward to dealing with that.

You maintain your optimism?

Oh yes, yes. Lots of challenges, both scientifically and in terms of having enough resources, and sustaining adequate attention - we recognize that malaria is not the only king in town. We have to work with others; it has to be an integrated process. But we know that we could have a major effect on malaria. We know that malaria can eventually be eradicated.

We think that's the only way forward, but it requires that we have a long-term sustained effort, and we are committed to doing that.

The Bill & and Melinda Gates Foundation is a contributor to AllAfrica's development reporting project.

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