While massive strides were made in the fight against malaria at the turn of the century, progress has plateaued in recent years, proving just how difficult it is to eliminate the deadly disease.
The World Health Organization on Wednesday launched a new initiative aiming to put an end to the transmission of malaria in 25 countries by 2025. This is a similar venture to the so-called E-2020 initiative set out in 2016, which identified 21 countries that could beat malaria by 2020.
A life-threatening disease transmitted to people through the bites of parasite-infected female Anopheles mosquitoes, malaria is both preventable and curable. Still, an estimated 229 million people are infected worldwide, killing 400,000 annually, with two-thirds being children under five according to WHO.
The new report examines the progress made in freeing the world of one of the deadliest diseases, zoning in on countries that have reported zero indigenous cases such as Algeria, Cabo Verde and Paraguay.
“Between 2002 and 2015, the global response against malaria was at a record high, with unprecedented progress witnessed in the fight against malaria. Cases globally reduced by over 40 per cent and with such major progress that happened in that timeframe, this pushed for high impact cost-effective interventions, moving the conversation to elimination,” said malaria expert, Alexandra Cameron of Unitaid, a hosted partnership of the World Health Organization.
Countries have made excellent progress as highlighted in the report, with Timor-Leste reporting only one indigenous case, while three other countries –Bhutan, Costa Rica and Nepal – reported fewer than 100 cases. Yet the journey to malaria eradication is proving difficult, with progress plateauing in recent years.
Overcoming challenges. Difficulties persist when addressing such a tenacious disease, including the threat of imported cases of malaria from neighbouring countries to a malaria-free country.
Another prevalent problem is drug resistance and malaria-bearing mosquitoes being acquainted with insecticides, which have been long-used strategies in fighting off the disease.
Cameron explained that in high burden countries some people take drugs that are no longer recommended for treatment due to the resistance. This could be medication such as sulfadoxine pyrimethamine.
“However, it can still be an effective preventative drug, which is a difficult message to send to communities because on one hand they are being informed not to use it as treatment and on the other hand it is demonstrated to still work for malaria prevention in pregnant women,” Cameron said.
The world is not on track to achieving the 2030 goals. Although disruptions to malaria services predate Covid, the current pandemic has posed additional challenges to the malaria response. A recent Global Fund report found that Covid-19 has adversely impacted health systems and service delivery, where diagnoses for malaria for example fell by 31 per cent and antenatal care visits by 43 per cent in comparison to data from 2019.
“This is a significant challenge for malaria. The fear of contracting COVID at health facilities, stay at home messages if you have a fever and difficulty with transport to health facilities in the early days of the pandemic was challenging in malaria-endemic settings because we certainly don't want people that potentially have malaria to stay at home as they need to get tested and treated,” Cameron explained.
Yet there have been some success stories. “Past experiences such as Ebola help the malaria community to deal with health crises such as Covid. Using the past experiences at the very beginning the communities mobilised very quickly. For example, the distribution of the seasonal malaria chemoprevention, given to children under five, which is a very impactful intervention, went ahead delivering at the same levels planned for the 2020 target,” she added.
Biting back against the disease. RTS,S is the first and only vaccine demonstrated to significantly reduce malaria, and since 2019, vaccination programmes have been piloted in three countries – Ghana, Kenya and Malawi. The WHO is hoping to coordinate and scale these up to other areas with moderate-to-high transmission.
Dr Kate O’brien, WHO vaccines director said on Tuesday: “Ghana, Kenya and Malawi show that existing childhood vaccination platforms can effectively deliver the malaria vaccine to children, some of whom have not been able to access an insecticide-treated bed net or other malaria prevention measures.”
“This vaccine may be key to making malaria prevention more equitable, and to saving more lives,” she added.
Two years into the programme the four-dose regimen has been administered to more than 650,000 children. The programme is proving to be an effective malaria prevention mechanism when used in combination with other currently recommended tools, as it reduced episodes of malaria in children by 40 per cent.
Cameron stated that there needs to be an all-inclusive approach for prevention and treatment, taking into account all the ways in which people get malaria. The Bohemia Project funded by Unitaid for example reduces malaria transmission by giving ivermectin not just to humans but also livestock.
Vector control is the most effective strategy for fighting malaria. As ivermectin works by killing biting mosquitoes, it complements other malaria-prevention tools like “bed-nets, long-lasting indoor insecticide sprays, malaria vaccines and better medicines for treatment and prevention,” Cameron noted.
Apart from such tools, community-led action remains an effective way to counter the disease. Strikingly, the bulk of the world's cases and deaths are shouldered by the WHO African region, with some 94 per cent in 2019 alone. Still, malaria eradication is a global problem that needs to be tackled through internationally coordinated efforts by all stakeholders.
One of these community led programmes which targets high risk groups such as pregnant women and children, is currently being implemented in the Democratic Republic of Congo, Madagascar, Mozambique and Nigeria.
In the malaria-endemic countries, the disease causes as much as 10,000 maternal deaths, 20 per cent of stillbirths, and 200,000 newborn deaths annually. The project known as TIPTOP focuses on providing pregnant women with intermittent doses of sulfadoxine-pyrimethamine, a medicine that prevents malaria. However, this intervention is not being taken up at high rates.
“Therefore, what the project is aiming to do is use community distribution as a means of supplementing antenatal care and creating a local distribution channel for TIPTOP,” said Cameron.
Reason for hope. Although progress in the global response to malaria has stalled in recent years, a growing number of countries are achieving the target of zero malaria transmission. Being certified as malaria free is the official recognition by the WHO that a country has proven that there have been no indigenous cases of malaria transmission for at least the three consecutive years.
Since the turn of the century, 24 countries achieved this milestone with El Salvador being the latest to join the club earlier this year. China, which has reported zero indigenous cases of malaria since 2016, is similarly on the way to certification.
Countries however are warned to remain vigilant to stop the return of the disease.
“Together, they have shown the world that malaria elimination is a viable goal for all countries,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.
By 2030, the WHO and its partners want to reduce the malaria case incidence and mortality rate by at least 90 per cent, eliminate malaria in 35 countries and prevent the resurgence in all countries that are currently malaria free.
Telling Geneva Solutions what a malaria free world would mean, Cameron said: “Beyond the health benefits there is also a huge economic gain. The amount of resources used to combat malaria could be deployed to tackle other problems. If we do not tackle malaria it will become more difficult as resources run out and the population grows. We must eradicate it sooner rather than later to see the tremendous benefits.”