22 November 2013

Africa: New Push On Malaria

Photo: John-Michael Maas/GlaxoSmithKline
Trial participant being vaccinated, Siaya District hospital, by the PATH Malaria Vaccine Initiative.

Washington, DC — Malaria researchers believe that better coordination and new technologies, such as the use of vaccines and sophisticated disease mapping, can inject new life into the ambitious goal of eradicating the deadly illness.

For the past three decades, the key mandate of the malaria community has been promote the use of bed nets to control and reduce the spread of the mosquito-borne disease, and focus on the most vulnerable - African children.

A child in Africa dies every minute from malaria, according to the World Health Organization (WHO). Some 3.3 billion people in nearly 100 countries worldwide are at risk of the disease, most of them in sub-Saharan Africa.

But because of recent interventions, including the use of bed nets, administrating rapid diagnostic tests, and boosting treatment with artemisinin combination therapies, or ACTs - which have become the new standard in medication - malaria rates have fallen 33 percent in Africa and over 25 percent globally in the past decade, WHO says.

Because of these recent advances and the availability of new tools to fight malaria, the Bill & Melinda Gates Foundation has announced a plan to synchronize the efforts of the malaria community worldwide towards the goal of global eradication, building on the foundation's original eradication call of six years ago.

"One of the pivots in our strategy is investing in making things happen on the ground, as opposed to conceptual, upstream stuff," said Dr. Alan Magill, director of the Gates Foundation's malaria programme. "We think this is an extremely audacious goal - we know that. I also feel that literally hundreds of thousands of years of co-evolution have proven that we cannot live a healthy and productive life with malaria. We need to be without it."

Magill spoke on the sidelines of the American Society of Tropical Medicine and Hygiene (ASTMH) conference held in Washington, DC, last week, where the Gates Foundation made its announcement.

Historical Precedent

From 1955 to 1978, WHO and partner organizations worldwide launched an ambitious malaria eradication effort. Health workers attacked mosquito-breeding sites by spraying with the insecticide DDT and screened communities for the disease. Mass drug administration programs were carried out, and anti-malarials were given to millions of people.

Then in the late 1970's, drug resistance started to appear, first in Asia and then in South America. Political will began to falter and funding dwindled, so by 1978 the eradication effort was abandoned. After that, the use of bed nets became the main strategy for curbing the spread of malaria.

Then in 2007, the Gates Foundation called for taking up the eradication goal again. With renewed political and financial support as impetus, malaria experts are bringing back some of the old strategies that were abandoned in the last effort and bolstering them with new technology.

As the disease adapts, some older interventions, such as the use of insecticide-treated bed nets, are no longer working as well in some areas because of resistance. Mass drug administration, or the administration of drugs to whole populations irrespective of disease status, is one old approach coming back.

However, it is a race against time as the threat of resistance to ACTs grows, and scientists struggle to stay a step ahead of the malaria parasite's adaptations.

Alassane Dicko, a malaria researcher at the University of Bamako, has been looking at using mass drug administration in Mali during high infection season. Mali still needs to boost its human resources and funding, Dicko said, but he's optimistic.

"If we apply the current tools we have in Mali correctly, we can move to elimination. That's very clear," Dicko said.

Right now, there are 34 countries that could soon eliminate malaria, seven of them in Africa. However, moving countries from having low prevalence to eliminating the disease completely is difficult, said Dr. Roly Gosling, lead of the Malaria Elimination Initiative at the Global Health Group at the University of California, San Francisco. Malaria tends to persist in rural pockets while governments are often run by urban elites who are rarely affected by the disease and don't perceive it as a pressing health issue, he said. Infected neighboring countries can also undermine a country's eradication efforts.

"If you want to eradicate malaria, somebody has to work in the last mile," said Gosling, who helps countries with low endemic malaria eradicate the disease. "The politics of getting funding for a malaria elimination program is incredibly difficult. So we work by getting countries together in regional initiatives, which then makes it more politically powerful [to eliminate malaria.]"

Greater Focus on Vaccines

Malaria vaccines, which are now in clinical trials, will likely be a significant addition to the anti-malaria arsenal in the next few years, scientists say. These vaccines would be the first ever against a parasite, said Dr. Vasee Moorthy, who serves as the malaria vaccine focal point for WHO.

"I think it's really an optimistic time, but one needs to be clear that it's an incredibly tough task," Moorthy said. "It's blue sky science. Nobody's ever done it. It's not like building a jumbo jet, which is complicated but everybody knows how to do it."

At the ASTMH conference last week, Moorthy presented the updated Malaria Vaccine Technology Roadmap, which details the goals of the global research and development community. Among those goals: to develop and license a first-generation malaria vaccine by 2015, with an eye on eradication.

"The focus of the update is expanding. It's much more ambitious now," Moorthy said. "We want vaccines that can eliminate malaria."

One goal is to develop a next generation of malaria vaccines to prevent disease and death and to enable elimination by 2030, Moorthy said. Health practitioners are doing this through clear goals and close collaboration with agencies all over the world.

"There's definitely been a big shift. Back in 2006, we worked with the community to develop a roadmap for vaccines for malaria," said Dr. Ashley Birkett, director of the PATH Malaria Vaccine Initiative. "It was really focused on developing vaccines to address the biggest burden of disease and death...Then in 2007, that really changed because there was this renewed call for elimination and eradication."

There is no silver bullet for eradication - vaccines are one of many necessary tools, Birkett stressed. Their contribution will be to break the cycle of transmission of the malaria parasite from mosquito to human, and vice versa.

"If we're going to eradicate, it's got to be one vision. We've all got to be working more closely together," Birkett said. "The real push now is to say - the drug guys, the vaccine guys, the vector control guys, the rapid diagnostic test guys - you've all got to start working together. And I think that's a really critical thing."

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