Malaria remains an issue in Africa and parts of Asia, so we’re proud to present this deep dive in association with the World Health Organization on the most pressing questions about Malaria.
1. Drug resistance
Anti-malarial drug resistance is a threat to malaria control and has significant implications for global public health. Resistance has a major impact on the cost of global malaria control due to the need for new drugs and the costs of treatment failures.
ACT efficacy is threatened by the emergence of both artemisinin and partner drug resistance, typically resulting in less effective treatment. While there is evidence of artemisinin resistance in the Greater Mekong Sub region including Myanmar and Thailand, increased surveillance systems and improvements to health systems are minimizing the impact.
Developing new medicines to address drug-resistance
In partnership with various organisations, MMV is developing new combination therapies aiming to address the challenge of drug resistance by identifying molecules with novel mechanisms of action and antimalarial activity against all-known resistant parasite strains.
The goal is also to have simpler dosing regimens to improve patient compliance to treatment, which will in turn protect against the development of drug resistance in the future.Last year, Novartis launched a patient trial for KAF156, a next-generation antimalarial compound with the potential to treat drug-resistant strains of the malaria parasite. This work is done with scientific and financial support from MMV (in collaboration with the Bill & Melinda Gates Foundation).
KAF156 is currently being tested with a new formulation of lumefantrine in a Phase IIb trial. Trial centers are operational in Gabon, Gambia, Kenya, Mali, Mozambique, Uganda, Thailand, and Vietnam with Burkina Faso to be added in June. The trial will be run in a total of 15 sites across nine countries in Africa and Asia.
In partnership with MMV, GSK researches potential therapies to address two pressing needs in malaria drug research: treatments for drug-resistant strains of the malaria parasite and treatments for Plasmodium vivax, the strain of malaria that is predominant in Asia and Latin America.
Low adherence to current standard of care along with emerging resistances to ACTs, mainly observed in the Mekong region, have been identified as primary concerns. To contribute to address these needs, Sanofi is co-developing two compounds with MMV – OZ/Ferroquin (PhIIb): a single dose for uncomplicated Malaria Falciparum, active on resistant strains, and SAR441121 (pre-clinical). To pursue its contribution in achieving a world free of malaria, Sanofi continues investments to bring to market new drugs that meet WHO requirements.
2. Insecticide Resistance
Evidence of resistance to four of the most commonly used insecticide classes used in long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), has been found in all affected regions except Europe, with the majority being reported in the African region.
Of the 76 malaria endemic countries that reported standard monitoring data for 2010 to 2016, resistance was detected in 61 countries to at least one insecticide in one malaria vector from one collection site. In 50 countries there was resistance to two or more insecticide classes.
Resistance to pyrethroids – the insecticide class used in all ITNs – is widespread. The proportion of malaria endemic countries that reported pyrethroid resistance (of those that monitored for it) increased from 71% in 2010 to 81% in 2016; 16 of the 72 countries that monitored throughout this period did not detect pyrethroid resistance.
The prevalence of confirmed pyrethroid resistance differed between regions and was highest in the WHO African and Eastern Mediterranean regions, where it was detected in malaria vectors in over two thirds of all sites monitored.
3. Driving innovation
Using Google Earth and smartphones to track malaria outbreaks
DiSARM is a unique web application that uses Google Earth. Health workers in Botswana and Namibia are using it on tablets and smartphones to predict where malaria outbreaks will happen next.
They can upload their own data on where and when malaria cases have been occurring and combine it with real-time satellite data on weather and other environmental conditions within Google Earth to pinpoint where new cases are most likely to occur.
That way, they can get lifesaving tools to those who need them most — spray insecticide, distribute bed nets or give antimalarial drugs just to the people who still need them, instead of blanketing the entire country. Pilots are planned for Zimbabwe and South Africa.
In Mozambique, Malaria Consortium is running a programme called upSCALE, which involves using an interactive mobile phone app that covers all community health services. The app supports community health workers to screen new-borns and children for signs of childhood illnesses (malaria, diarrhoea and pneumonia), prompts them to check the child’s vaccination status, and offers them treatment and referral recommendations as appropriate. Data is reported in near-real time to health officials, informing them of disease outbreaks and low stock levels.
Alongside this, Malaria Consortium is working in collaboration with the Mozambican Ministry of Health and UNICEF to develop a digital strategy to strengthen health systems and community health delivery, which is to be scaled up in all provinces to create a national mHealth system led by the Ministry of Health. By doing so, Mozambique will be the first country to scale up a digital health strategy to this extent.
Data mapping transforming the fight against malaria in Zambia
Visualize No Malaria is an initiative of the Government of Zambia, PATH, the Tableau Foundation, and a number of other technology partners. Together, this coalition of tech companies are each applying their tools, resources and expertise in a united pursuit of malaria elimination. The result? Front line health workers are being armed with data visualization tools and analytical skills to improve reporting and to make informed decisions on managing malaria and deploying appropriate resources in their area.
Drones, monkey behaviour and malaria
London School of Hygiene and Tropical Medicine researchers are pioneering the use of drones for health and ecological research. They are being used to provide highly accurate information on changes to land, such as deforestation or changing types of agriculture to help understand the impact on the movement and distribution of people, animals and insects that carry disease.
This is a significant innovation as drones can repeatedly collect detailed information in real time at relatively low cost. The Monkey Bar project in Malaysia is a large multi-disciplinary study into a malaria parasite which was previously thought to only affect macaque monkeys and is now increasingly found to be affecting people. The research, funded by The UK Research Council Living with Environmental Change Initiative, involves using a drone to map changes in human, mosquito and monkey habits and correlating how those changes affect human infection.
Data gathered by the drone is being used alongside hospital cases, data on mosquito abundance and monkey and human movement to understand risks. In addition to Monkeybar, researchers are also exploring opportunities to map public health emergencies and estimating population sizes in hard to reach places.
Launched by the Asia Pacific Leaders Malaria Alliance (APLMA), M2030 is a groundbreaking partnership that raises funds and inspires corporate action to end malaria in Asia.
For the first time ever, consumers and some of the largest businesses in Asia are joining forces. By combatting malaria in their own countries, they address the regional problem posed by drug-resistant malaria before it becomes a global issue.
M2030 partners include a select group of Asia’s leading business, including Dentsu Aegis Network, the DT Group of Companies (Thailand), Shopee (the leading e-commerce platform in Southeast Asia and Taiwan), Tahir Foundation (Indonesia), Yoma Strategic Holdings (Myanmar) and The Global Fund.
4. Medical innovation
Rectal artesunate product for children with severe malaria receives WHO approval
Indian pharmaceutical company, Cipla Ltd, has received approval from WHO’s Prequalification Programme for their 100mg rectal artesunate suppositories (RAS), for the pre-referral management of severe malaria. The approval will expand access to the drug and help save the lives of thousands of children who contract severe malaria.
This much-awaited approval, achieved with support from Medicines from Malaria Venture and funding from Unitaid, will enable countries to procure the life-saving suppository with donor funds and distribute it to rural areas, where it is most needed.
Severe malaria can kill within 24 hours if left untreated, and travel times to hospital can be long, particularly for children from remote rural communities.
A single dose of RAS 100mg, given as soon as a presumptive diagnosis of severe malaria has been made, can halve the likelihood of disability and death for young patients living 6 hours or more from a health facility where they can receive recommended severe malaria treatment (WHO TDR 2009 study). This is life changing for children who do not have quick access to injectable artesunate.
To date, Cipla has registered RAS in two high-burden countries and the dossier is under review in a further 14 countries. Close to 150,000 treatments have been distributed to countries by the company. For 2018, orders for RAS have been placed to supply close to a dozen high-burden malaria countries.
5. Malaria in complex situations
Complex situations, whether as a result of natural factors such as excessive rains, flooding or earthquakes, or human-made ones such as conflict and political crises, often disrupt service delivery, and the implementation of interventions. Where the ecological conditions are suitable for malaria, such situations often result in increased malaria transmission, disease and deaths. The burden of disease can be exceptionally high among the most vulnerable, such as children and pregnant women, especially when worsening nutritional conditions impair their capacity to fight the disease.
As the Monsoon season in Bangladesh is just weeks away, there are fears of a malaria outbreak amongst the estimated 650,000 Rohingya Muslims living in makeshift refugee camps in the Chittagong Hills and Cox Bazaar area of Bangladesh, who have crossed the border from Rakhine state in Myanmar. The combination of poor sanitation, emergency sub-standard housing and approaching rains provide the perfect conditions for a significant outbreak, especially amongst the large population of pregnant women and children under five.
Effective surveillance of malaria cases and deaths is essential for identifying which areas or population groups are most affected by malaria, and for targeting resources to communities most in need and ensuring smart investments. Such surveillance also alerts ministries of health to epidemics, enabling control measures to be intensified when necessary.
Cases and deaths from the surveillance system reported by countries are often from the public health sector, predominantly through passive case detection. In elimination settings, data on cases may also be recorded during active case detection. Often, data from the private sector remain sparse, and in countries with moderate to high transmission it is possible that a substantial proportion of patients who do not seek care remain undocumented by the surveillance system.
A strong surveillance system therefore requires high levels of access to care and case detection, and complete reporting by all health sectors.