Fight against malaria 2018

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IN THIS ISSUE

Sir Richard Feachem Shrinking the Malaria Map: “We must continue to eliminate progressively from the endemic margins inwards.”

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Regina Rabinovich MD We must innovate our approach to eliminating malaria through classical research, product development, and new ways of combining interventions.

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Dr Kesete Admasu “2018 needs to be a momentous year in the global fight against malaria.”

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Progress in tackling malaria has stalled

In April 2001, African leaders signed the Abuja Declaration and Plan for Action with a pledge to halve malaria mortality by 2010. At the time, global investment in malaria was less than US $100 million, far below what was needed to control a disease that claimed nearly 1 million lives annually.

The development of new vector control tools such as long-lasting insecticidal nets, new drugs to replace failing ones, and new approaches for point-of-care diagnosis marked a turning point in the fight against malaria. The formation of the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002 and other financing mechanisms allowed for the wide-scale deployment of these tools, leading to a period of unprecedented investment and success in malaria control.

By 2015, mortality rates in Africa had plunged by an estimated 66% among all age groups and by 71% among children under five. The

malaria target of the 2000 Millennium Development Goals – which called for halting and beginning to reverse the global incidence of malaria by 2015 – was achieved and, in some countries, surpassed.

However, if we fast forward several years, the outlook is far less bright.

According to the World Health Organization’s latest World Malaria Report, released at the end of 2017, the world is not on track to reach critical 2020 targets of our global malaria strategy.

Progress in the malaria response has unquestionably stalled.

In 2016, the estimated number of malaria cases worldwide reached 216 million, marking a return to 2012 levels. Deaths stood at 445,000 in 2016, a similar number to the previous year.

With hindsight, we see an important shift in the trajectory of this disease dating back at least four years, when the declining trend in malaria cases and deaths plateaued.

The WHO African Region continues to shoulder approximately 90% of cases and deaths globally. Eleven countries – all but one in Africa

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– carry more than 70% of the burden of this disease. Clearly, intensified support and investment in these countries will be critical to get the malaria response back on track.

Dr Pedro Alonso Director, WHO Global Malaria Programme

In 2016, the estimated number of malaria cases reached 216 million, marking a return to 2012 levels On a global scale, stagnant funding is a real concern. The estimated investment of US $2.7 billion for malaria in 2016 represents only 41% of our annual funding target for

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2020. Worryingly, in many high-burden countries, per capita funding for the population at risk of malaria was lower in 2014-2016 compared to the previous 3-year period. Inadequate funding has led to major gaps in access to core malaria-fighting tools, especially in Africa.

As the WHO Director-General stated in the foreword of the latest World Malaria Report: “If we continue with a ‘business as usual’ approach – employing the same level of resources and the same interventions – we will face near-certain increases in malaria cases and deaths.”

The choice before us is clear.

With the required resources and political momentum – as well as an intensified effort to develop new and improved tools and strategies – we can move the needle closer towards the end point we seek: a world free of malaria.

Find out more on fightagainstmalaria.com

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How to tackle the scourge of malaria — from the people who know best Increased domestic funding, better surveillance and a focus on operational research are among the solutions outlined in a new study about fighting malaria in African countries.

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D

r Richard Kamwi is optimistic that a malaria-free Africa is a real possibility. He’s seen enough success stories in many countries, to make him believe it can happen.

“I remember the situation in Namibia, my own country, in 1990,” he says. “Back then, we had a high incidence of malaria. Out of a population of 1.5 million, over 7,000 died from the disease that year. Fast forward to 2012, and how many malaria cases did we have? Two hundred. How many people died from it? Four.” This proves that, with the right approach, malaria can be controlled — or even eliminated.

Of course, achieving that level of success meant working around the clock and implementing well-resourced and effective malaria control strategies. So Kamwi is emphatically not suggesting that there is a simple fix. Indeed, evidence shows that prevalence of this terrible disease — which kills a child every two minutes — is increasing. “But we cannot lose hope,” he says. “That should not be an option.”

Why complacency is a killer However, complacency is not an option either, he insists. The trouble is, it’s tempting for governments, NGOs, and donors to take their eye off the ball when the burden of disease is reduced, and when other more pressing health problems present themselves. Keeping a focus on malaria is, therefore, not just important. It’s essential.

Take the example of Namibia again. After those heartening statistics from 2012, cases of the disease increased in 2016 (more than 24,500 were recorded — although deaths remained relatively low). “Clearly,” says Kamwi, “this tells us that complacency can be a real problem.”

If anyone knows about the challenges of the disease it’s Kamwi, who is an expert in the field of malaria elimination. He served for 15 years as Deputy Minister and then Minister of Health in Namibia, and is currently Africa CDC Champion (Centres of Disease Control and Prevention) and Ambassador of Elimination 8 (E8), a platform for regional collaboration towards elimination in the Southern African Development Community (SADC) region. He is also co-chair of a newly published opinion research study entitled MalaFA (Malaria Futures for Africa), which captures the thoughts of 68 African malaria experts in 14 sub-Saharan African countries “in the face of increasing challenges.” The study was commissioned by Novartis, the healthcare company that launched fixed-dose artemisinin-based combination therapies (ACTs), the current gold standard treatment for malaria, and provides them without profit to malaria-endemic countries.

Without donor funding, we can expect a rise in malaria The study’s respondents make various messages loud and clear.

One main concern is that current malaria programme funding models are inadequate, due to an imbalance between domestic and donor funding. Domestic financing must therefore increase substantially. “As much as I appreciate what donors do, some member states can become over-dependent on them,” says Kamwi. He advises that, “sustainable funding models must be developed which incorporate domestic and donor

some areas. “We see this happening in countries that are categorised as ‘middle income’,” says Kamwi.

“Donors pull out because they think these places are ‘rich’ — but this is not the case. The MalaFA study makes quite clear to donors that, without them, we can expect a resurgence of malaria in Africa.”

Dr Richard Nchabi Kamwi Ambassador SADC Malaria Elimination 8

Out of a population of 1.5 million, over 7,000 died from the disease that year. Fast forward to 2012, and how many malaria cases did we have? Two hundred. How many people died from it? Four.

funding with emphasis on alignment to national priorities.”

Even so, no-one should underestimate the importance of donor funding, which is declining in

The importance of operational research The study also highlights the importance of good organisation and delivery of both existing and new interventions, and notes that — perhaps as a result of successful prevention campaigns — the use of prevention tools may be declining.

“Optimal application and utilisation of current tools is vital,” says Kamwi. “I would say these tools are not being used to their fullest extent in some countries, which is a cause for concern.”

Also, Kamwi cautions, surveillance of drug and insecticide resistance must be increased and strengthened. “Surveillance is a cornerstone. Inadequate reporting and monitoring of the current tools makes it difficult to measure the real impact of the disease burden. And while we remain extremely grateful for the old tools that have worked in so many cases, we need to invest in research and development for new tools in the fight against malaria.

This is because resistance is now a major threat. In the long run, lives will continue to be lost if the drugs and insecticides used in vector control are no longer effective.”

This means that operational research needs to be strengthened, although it’s an area that suffers from underfunding. “Countries need to build local capacity,” says Kamwi.

“We need to train and retrain our own people — which is more cost effective — instead of relying heavily on expatriates, for example.”

Counterfeit medicines and lack of political will hinder elimination The scourge of counterfeit medicines is another major issue highlighted by the study — one that can actually cause deaths in some cases. “Counterfeit medicines also potentially increase the risk of drug resistant strains developing,” says Kamwi.

“We need to work together collectively — WHO, INTERPOL, Africa CDC, E8, etc — to fight against counterfeit medicines. It’s a real problem and we don’t need it.” And, as mosquitoes don’t respect political borders, he also has a stark message about the continued need for outbreak collaboration and cross-border monitoring. Neighbouring countries must join forces to halt the spread of disease. “If we stop working together, then we are looking for trouble. Our people will die.”

Worryingly, the study’s respondents had mixed feelings about the likelihood of 2030 malaria targets being met. Politicians and senior ministry officials were, generally, more optimistic; but most academics, researchers and NGOs were less so.

This is probably because, historically, there has been a lack of coherent political will and strategy regarding malaria elimination across Africa, says Kamwi.

Yet things may be changing. Success in countries such as Botswana, Swaziland, and South Africa show that the push-back against malaria can be effective. “I am now seeing a political will to fight the disease like never before,” says Kamwi. “So let us be optimistic about the future.” The prize is too valuable to let slip from our grasp now.

Tony Greenway Read full report on novartis.com bit.ly/MalaFA-report

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Defeating malaria in Asia Pacific takes political will In little more than a decade, an Asian child in a remote, rural community will fall ill with fever following a mosquito bite. After accurate diagnosis, she will be given effective treatment and make a full recovery. A community health worker will determine there are no other cases. It will be the last case of malaria in Asia Pacific. This is not a fantasy, but a tangible moment within our grasp.

Over the past 15 years, there has been a massive international donor effort to tackle malaria in the Asia Pacific region. This effort has driven greater access to medicines, distribution of bed nets and better screening and diagnosis. These actions halved the burden of the disease, averting over 80 million cases and over 100,000 deaths in our countries.

In 2014, the heads of 18 Asia Pacific governments set an ambitious goal: to eliminate malaria in the region by 2030. They formed the Asia Pacific Leaders Malaria Alliance (APLMA) to strengthen their anti-malaria efforts, protect hard-won national gains and, ultimately, to defeat the disease

www.m2030.org

business leaders are joining forces in Indonesia, Myanmar, Thailand and Vietnam to combat malaria in their own countries while contributing to regional success.

But, according to the 2017 World Malaria Report, overall progress has stalled. In 2016, there were an estimated 216 million cases of malaria in the world, five million more than in 2015.

Ruby Shang Chair of the Asia Pacific Leaders Malaria Alliance (APLMA) Board of Directors

National malaria responses need to adapt and evolve

throughout the region.

Local governments have backed the political pledge with budgetary assurances. Since 2012, countries in Asia Pacific have increased their domestic financing for malaria by 44%; estimates indicate another 40% increase between now and 2020.

Over the same period, nations in the Greater Mekong Subregion have increased domestic investment against the disease by 230%.

Among other health financing innovations, APLMA is creating new platforms, such as ‘M2030’, to help raise funds and inspire action to end malaria. With M2030, Asian consumers and

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This is a wake-up call that our progress is at risk. Emerging forms of drug-resistant malaria in the Greater Mekong Subregion threaten a resurgence in malaria-related deaths. This would strain healthcare systems, cause serious economic impact and create a hazard for neighbouring countries.

The malaria control strategies of the past will not be as effective in the future. Eliminating malaria requires greater ingenuity in programme implementation, innovative health technologies – such as new medicines and insecticides – and approaches that unite diverse sectors, national efforts and regional actions.

In 2016, Sri Lanka received official ‘malaria-free’ certification from the

info@aplma.org www.aplma.org @APLMA_Malaria

World Health Organization for successfully eliminating the disease.

The extraordinary achievement was the result of years of hard work and the nimble adoption of new anti-malaria approaches.

Historically, malaria has been widespread in China. In 2010, the Chinese government launched a national malaria elimination programme, calling on 13 different ministries to integrate malaria elimination into their work. At the time, China reported almost 5,000 locally-acquired cases of malaria annually. In 2017, there were no locally-acquired cases, according to preliminary reports. Once confirmed, this will be an important milestone for regional malaria elimination efforts; a major achievement for a nation and a malaria epidemic of this size.

From the vast geography of China to the island nation of Sri Lanka, the recipe for success requires a united effort to galvanize political will. Following China and Sri Lanka’s achievement, senior officials from Asia Pacific governments agreed to establish national malaria elimination task forces. Their goal was to drive political engagement,

momentum and accountability.

To succeed, all national programmes need to work together with clinical and academic bodies, the corporate sector, defence and military agencies, civil society and local communities.

To succeed, the GMS countries need to work as one, across borders.

Malaria-endemic countries must build national task forces Defeating malaria takes more than better screening and more bed nets— it takes political will. To make malaria a thing of the past, all malaria-endemic countries must establish national task forces as soon as possible.

We already know where we will find the last case of malaria in the Asia Pacific region: most likely in a remote, under-resourced, rural community along a heavily forested border. When it will occur depends on how well our countries are able to work together across sectors and borders to meet our 2030 goal.

On our own, none of us can defeat malaria. Together, we are close to the moment of realising a malaria-free Asia Pacific. What we must do is act on it, now.

Kesetebirhan (Kesete) Admasu, Pedro Alonso, Constance Bart-Plange, Karen Day, Arjen Dondorp, Abdoulaye Djimdé, Richard Feachem, Iveth González, Brian Greenwood, Janet Hemingway, Richard Nchabi Kamwi, Dominic Kwiatkowski, Kevin Marsh, Nafsiah Mboi, Winnie Mpanju-Shumbusho, Bernard Nahlen, Francois Nosten, David Pearson, David Reddy, Melanie Renshaw, Carol Sibley, Larry Slutsker, Marcel Tanner, Leann Tilley, Neena Valecha, Marijke Wijnroks, Dyann Wirth, Yongyuth Yuthavong

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The Global Fund: Malaria elimination efforts in Africa Senegal

In Africa, the continent with the highest malaria burden, the percentage of people at risk for malaria who have access to mosquito nets grew from 6% in 2005 to 62% in 2015. Global health partners support the rollout of mass distribution campaigns of insecticidetreated nets to protect communities.

Niger

PHOTO: THE GLOBAL FUND/DAVID ODWYER

PHOTO: THE GLOBAL FUND / ANDREW ESIEBO

PHOTO: THE GLOBAL FUND / NANA KOFI ACQUAH

The growing corps of community health workers in Senegal have transformed health care delivery by The growing corpslifesaving of community health workers in Senegal have providing treatment in hard-to-reach rural areas transformed health delivery by providing lifesaving treatwhere healthcare facilities are either under-resourced or nonment in existent. hard-to-reach rural areas where healthcommunity facilities arehealth either As caregivers and educators, under-resourced or nonexistent.

As caregivers educators, workers have significantly increased early and malaria referral community health workers have signifi cantly increased early rates, eliminating potentially deadly delays. malariaSenegal’s referral rates, eliminating potentially deadly malaria-related deaths have fallen bydelays.

57% since Senegal’s malaria-related deaths have fallen by 57% since 2002, and 33 districts have reached the pre-elimination 2002, and 33 districts have reached the that pre-elimination stage. stage.

This milestone indicates transmission rates This milestone indicates that suffi transmission ratestohave have dropped ciently enough start dropped shifting sufficiently enough to start shifting from the goalofof programmes fromprogrammes the goal of ‘control’ to that ‘control’ to that of ‘elimination’. ‘elimination’.

Chad

The investments in integrated healthcare systems and malaria prevention programmes have led to a significant decline in malaria cases in children under fiveyears old, which is also contributing to a steep decline in child mortality.

It helps to have friends in tech (Unless you’re a malaria parasite) PATH and the eight tech companies in the Visualize No Malaria partnership pledge to stand with frontline health workers and the people of Zambia to eliminate malaria by 2021. From data to diagnostics to a pipeline of malaria vaccines under development, PATH is dedicated to defeating this deadly disease.

LEARN MORE AT Photo: PATH/Gabe Bienczycki

path.org

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Malaria progress has levelled but new drugs are in the pipeline

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Innovation can help us win the fight against malaria There is a great deal of truth in the saying, “Send a net, save a life. ” Vector control – the prac-

George Jagoe Executive Vice President Access and Product Management, Medicines for Malaria Vaccines (MMV) With progress stalling in the treatment of malaria, the development of new medicines to prevent and treat malaria are a top priority if we are to prevent a backward slide to the dark days of the 1990s.

Less than 20 years ago, the situation for those living in countries worst affected by malaria was dire, says George Jagoe of the Swiss not-forprofit foundation, Medicine for Malaria Venture. “Existing medications had become wooden bullets in the clinical armoury because of drug resistance,” he says. At that time, clinicians expressed frustration and despair at their inability to offer effective treatments to sick patients. The vast majority of the time, those clinicians were coping with very ill young children whose immature immune systems leave them most vulnerable to malaria.

Beginning in the mid-2000s, thanks to widespread adoption of new artemisnin-based medicines and a significant increase in R&D investments, improvements in antimalarial treatments have contributed to large reductions in malaria-related mortality rates.

Over the last decade, drug treatments for children between 0–5 years (along with other interventions) have resulted in millions of lives saved, says Jagoe.

Resistance is a threat to drug efficacy When it comes to malaria, however, drug resistance is an ever-present reality. In the latest World Malaria report, the World Health Organization noted that the trajectory of the disease had changed. Between 2014-2016, the number of deaths from malaria has increased, returning to 2010 levels. Multiple factors have contributed to this backsliding.

“As Alan Magill, a leading malarialogist, once said, worst case, we may end up running as fast as possible just to stay in place in the race to eliminate malaria – and fatigue will set in,” Jagoe says. “We need smarter deployment of our existing tools, and continued investment in better tools if we are to outrun the disease. Keeping pace with malaria by making incremental improvements will not work.”

Ensuring the continued efficacy of existing drug treatments before resistance strikes is something that keeps Jagoe and others like him ‘awake at night’, he says.

As someone whose work focuses on ensuring access to the most effective and appropriate medicines, Jagoe believes that part of the solution will require continued development of improved treatment options. A mosaic of new therapeutic options to prevent and treat malaria are being developed – as well as specific interventions such as targeted population-based treatment strategies to uproot malaria for good in specific settings.

Single-dose drug by end of 2018 Fortunately, a number of new drugs in development are providing scientists with grounds for cautious optimism. These include antimalarials that can prevent the disease, as well as ones to treat severe malaria, which may result from delayed diagnosis and/or access to oral treatment for uncomplicated malaria.

Another drug treatment for a relapsing form of malaria (vivax malaria) may come to market before the end of 2018, according to Jagoe, where a single-dose cure could be used to replace the current 14-day treatment to stop the relapse.

The existing, 14-day therapy frequently results in poor compliance, due to the duration of treatment. As such, Jagoe notes that the new single-dose cure could prove ‘revolutionary.’

“Without new drugs, we risk a return to the same situation with malaria that we saw in the 1990s,” he says. “Thankfully, more effective tools are in the pipeline so there are reasons to be hopeful.”

Victoria Briggs

tical science of keeping mosquitoes away from people – has been the single most effective factor in accelerating progress against malaria over the past two decades.

S

eventy-nine percent of the reduction in the global number of malaria deaths has been achieved by the application of indoor residual sprays (IRS) and the distribution of insecticide-treated bed nets (ITNs). Millions of lives have been saved thanks to the use of these simple tools in households across sub-Saharan Africa.

The challenge is that this progress has relied on just four classes of insecticide for IRS and just one class of insecticide – pyrethroids – for ITNs. The result has been a rapid and predictable increase in mosquito resistance to these chemical agents. Pyrethroid resistance has been reported in 81 percent of the countries that monitor for it, and mosquitoes are becoming increasingly resistant to available IRS compounds as well.

But there is good news on the horizon, and that news is the outcome of more than a decade of hard work, advanced planning and partnership amongst governments, UN agencies, academic research institutions, charities and the private sector.

In 2008, many of the world’s leading global crop protection companies opened their chemical libraries to be used in collaborative research.

Using rapid, state-of-the-art research tools, 4.5 million chemical compounds were examined for their effectiveness against mosquitoes and to ensure that they were safe and non-toxic amongst humans.

Nine completely novel chemical classes have now been identified that are ready to be moved forward into candidate selection for product development. These novel classes will reduce the world’s reliance on a mere handful of active ingredients for mosquito control and facilitate the roll out of new rotations and combinations of control methods.

Last July, a new type of insecticide-treated net was developed.

This net combines existing pyrethroid compounds with a repurposed agricultural pesticide, chlorfenapyr, and field trials in Benin, Burkina Faso, Tanzania and Cote d’Ivoire have demonstrated the net’s effectiveness against local insecticide-resistant mosquitoes.

Innovations like these have been made possible by the power of public-private partnership, and it’s

Dr Trevor Mundel President, Global Health at the Bill & Melinda Gates Foundation

exciting that the world’s major crop protection companies have formally announced that they will work as a consortium toward the development of a variety of innovative vector control products.

Beyond indoor sprays and bed nets, there are many more potential tools in the pipeline. A recent study in Mali demonstrated the effectiveness of a device that attracts mosquitoes using the synthesized scents of the various flower and fruit nectars that form the base of their diet.

When mosquitoes feed on these sugars, they are exposed to a poison. The amazing potential of these attractive toxic sugar baits (ATSBs) is they can be hung on the outside walls of rural houses and eliminate biting mosquitoes before they are mature enough to transmit malaria.

Private-sector partners are working with malaria control programs to evaluate the use of low-cost drones as tools to map the landscapes surrounding rural communities and identify local water sources that provide breeding grounds for mosquito populations. This approach could help public health workers identify water sources that need to be treated with chemicals that are toxic to mosquito larvae but have no effect on people, thanks to our very distinct nervous systems.

One research team is exploring how to introduce genetic changes in a handful of mosquito species that could dramatically reduce their populations, interrupting malaria transmission. This concept, known as gene drive, could be applied to the three or four species of mosquito in Africa that are effective disease

vectors while sparing the other 3,500 species of mosquito around the world that play no role in making humans sick. As Bill Gates recently noted in an article for Foreign Affairs, because gene drive is a new tool, it raises legitimate questions and understandable concerns about possible risks and misuse.

Wherever gene editing research is conducted, it should be done under WHO’s established guidelines for biosafety and bioethics, and it should involve the active participation of all relevant stakeholders, especially scientists, civil society representatives, government leaders, and local communities in countries where it could be deployed as a malaria-elimination tool.

Beyond new tools to increase mosquito control, we are also developing fascinating technologies that can be used to monitor progress. Maggy Sikulu-Lord, a Kenyan-born entomologist based at the University of Queensland in Australia, has developed a way to rapidly sample and determine the average age of mosquito populations with near-infrared microscopy. Using easily identifiable biomarkers, lab assistants with minimal training can determine whether vector control methods are killing female mosquitoes before they are old enough to transmit malaria. We hope that this rapid assessment tool can be effectively deployed to ensure that malaria control efforts are working or to identify the best ways to optimize their impact.

Other researchers are developing new tools to capture mosquitoes and quickly sequence their genomes.

As the cost of genome sequencing becomes increasingly affordable, it could provide a readily accessible way to track changes in mosquito populations over time and monitor for the development of resistance.

If we can develop an array of new tools to keep the mosquitoes that transmit malaria away from people, there is no reason why we can’t eliminate deaths caused by the disease and ultimately end malaria for good. The most essential resource in this effort will be the power of partnership, and I am excited to be in London this week as we forge new ventures to translate innovation into action.

Read more on fightagainstmalaria.com

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Mosquitoes adapt their behaviour to resist insecticides Mosquito resistance to insecticide is threatening to undermine the global effort to eradicate malaria. A new generation of vector control products are needed if the disease is to be successfully stamped out.

The year 2000 marked a significant turning point in the development of malaria. The World Health Organization launched a global public health campaign to eradicate the disease.

Since that time, an estimated 663 million clinical cases of malaria have been successfully averted. This success was often the direct result of ‘vector control’ products.

“Vector control has been the hero of the malaria success story to date,” says Professor Nick Hamon. “Insecticide-treated bed nets and indoor sprays are the main forms of vector control products and there is a real recognition of the role that the two have played in malaria reduction.”

Mosquitoes are becoming resistant to sprays Despite sustained efforts to eliminate the disease, malaria still claims the life of a child every two minutes.

Dr Nick Hamon CEO IVCC and adjunct Professor of Entomology, North Carolina State University

Malaria still claims the life of a child every two minutes.

In 2016, malaria was responsible for almost half a million deaths, and last year was the first year since 2000 where an annual drop in reported cases failed to occur.

“There is widespread mosquito resistance to one of the compounds used in the bed nets. It’s a similar story to the antibiotic one in humans. If you use the same product over time, it eventually loses its impact,” says Hamon. “There are multiple species of mosquitoes and, as they evolve, they adapt to the pesticide.”

Stamping out insecticide resistance has now become an urgent priority. The hope, says Hamon, is that several new compounds can be developed that can be used to overcome resistance and reduce malaria reoccurrence rates in high-risk areas.

Mosquitoes are learning to bite outdoors, away from sprays Bringing new insecticides to market is a long process, and one that is fraught with potential failure.

“The disease is challenging to eradicate, not least because, for the companies who make insecticides, there will never be a financial return on investment on any

products they develop,” he says.

Because of the costs involved in formulating new insecticides, scientists are reliant on global crop protection companies allowing them to access their vast chemical libraries where the key to overcoming malaria resistance is likely to be found.

Crop protection companies have long been a driving force in the battle against malaria, supporting the research, development and maintenance of insecticide supplies, says Hamon. And they have saved millions of lives in the process.

“We work very closely with a number of global companies, screening their chemical libraries for potential compounds that might provide us with solutions to resistance. There are a number of new compounds already in pre-development, and we hope to get some of them into full development by 2021,” he says. “If that proves successful, it could give us a whole new suite of malaria interventions.”

With scientists in possession of additional insecticides, the active ingredient used in bed nets and indoor sprays can be used in rotation to overcome, or at least slow down, resistance. It is also hoped that new compounds can be developed to help

control the spread of malaria outdoors.

“Mosquitoes have adapted to indoor insecticides by altering their behaviour and becoming more active outside, in the open air,” says Hamon.

“It’s crucial, therefore, that we develop products that can be used by people who work outdoors, who are travelling in affected areas, or anywhere that there are migrant populations or refugee camps.”

Insecticide development can be slow to market As with the development of any new drug or compound, the testing stage of new insecticides comes without guarantees. Stringent safety and environmental measures are in place, and bringing new products to market takes a considerable amount of time.

When it comes to the future of malaria though, Hamon is hopeful.

“We have an exciting pipeline of products in development that could prove to be game-changing. Eradication is possible,” he says. “We’ve successfully managed it in most areas of the world and, by integrating drugs and vaccines with new vector control products, we can get rid of the disease for good.”

Victoria Briggs

Together we can change the world.

Great strides have already been made in the journey to beat malaria. Thanks to the hard work, commitment and collaboration of the world’s leading crop protection companies, advanced vector control solutions are providing hope across continents, countries and communities.

Now it’s time to make even greater strides to beat malaria for good. With renewed resolve and a dedicated initiative, we believe we can achieve zero cases of malaria by 2040. To learn more about the new ZERO by 40 initiative, visit ZEROby40.com.

PARTNERS

IVCC is funded through the generous support of the Bill & Melinda Gates Foundation, DFID, USAID, UNITAID and the Swiss Agency for Development and Cooperation (SDC).

#ZEROby40

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We must act now to stop malaria in its tracks Dr Kesete Admasu CEO of the RBM Partnership to End Malaria

W

e are standing at a crossroads in the fight against malaria. Funding for malaria treatments and prevention has plateaued.

Millions of lives and decades of investments are at risk. Today, half the world is still threatened by this preventable, treatable disease that takes a child’s life every two minutes. Malaria is a major cause of global poverty, hampering economic growth in malaria-affected countries.

We must act now to stop malaria in its tracks. 2018 needs to be a momentous year in the global fight against malaria. We must ensure renewed attention and commitment to ending malaria for good – from the highest political level down to local communities where the everyday fight against the disease is being fought. We need those who will show leadership, put up new resources, lend their talent, their money or their knowledge, to reducing cases and deaths today while we innovate for tomorrow.

If we don’t seize the moment, our hard-won gains against the disease will be lost. Now is the moment to accelerate progress towards ending history’s oldest and deadliest killer. With renewed focus and commitment, we can reduce deaths and cases of the disease.

O

Regina Rabinovich, MD President, American Society of Tropical Medicine and Hygiene

ver the past two decades, progress in malaria has resulted from new funding that made the introduction and scale of innovations possible. Tools that today are the mainstay of malaria treatment and prevention – namely bed nets, rapid diagnostic tests and artemisinin combination treatment – were not available in 2000. Similarly, within a decade we will likely be using new tools that will improve our ability to overcome drug and insecticide resistance as these emerge. A vaccine that interrupts transmission of the parasite and better ways to combine these in a “toolbox” to achieve elimination

when used broadly in the community.

Innovation encompasses classical research, product development, and new ways of combining interventions and using a variety of tools to measure the results in order to optimise the programme. Innovation means that several critical ingredients have to be available: good science, industry partners to develop and manufacture products, adequate funding and experts from diverse fields.

A key element is the human capital required. Unlike the malaria eradication programme in the 1950s, which falsely convinced young scientists that the problem had been largely solved, today we understand that engaging the next generation of scientists – and new areas of science – will be critical to advance the feasibility of elimination in the hardest hit countries.

MEDIAPLANET PHOTO CREDIT: MALARIA NO MORE UK

David Beckham: Why I’m adding my voice in the fight against malaria We can’t afford to take our eye off the ball in the fight against malaria, an entirely preventable but deadly disease, says David Beckham.

But with teamwork, we can beat it.

I’ve seen first-hand the devastating, life-shattering impact that malaria can have for families in Sierra Leone and South Africa in my role as a UNICEF Goodwill Ambassador. Parents who have lost their children — the greatest pain — and it could have been prevented.

As a dad, I just can’t imagine living with the knowledge that my child could catch a deadly disease overnight. The reality of putting your son or daughter to bed, knowing that when they wake up they could be infected because of a single, stoppable bite must be unbelievably stressful.

And, at the heart of that worry, is a disease that’s utterly preventable and costs less than a cup of tea to treat.

The UK is making a real difference The day I first got involved in the fight to end this awful disease, the best part of a decade ago, isn’t something I’ll forget in a hurry. Playing tennis at Wembley Stadium over the world’s longest mosquito net doesn’t happen every day. And when it’s against a fresh-faced young talent called Andy Murray, it tends to stick in the mind.

Success takes hard work and commitment. Since the year 2000, child deaths from malaria have been slashed by more than 60%.

That’s amazing progress and proof

David Beckham Malaria No More UK Leadership Council Member and UNICEF Goodwill Ambassador

that the UK’s generosity when it comes to giving aid makes a real difference to real lives.

An increase in malariarelated deaths But malaria comes back stronger if you take your eye off the ball. I was worried by the news at the end of 2017 that progress to save lives from malaria stalled and deaths looked to be rising again. It’s a wake-up call that we can’t be complacent. It’s vital that the fight continues.

Nets still play an important role but we need to advance our tactics, test, treat and track the disease and find new ways to kick it out.

That’s why I joined forces with Ridley Scott’s team to create a film to launch a new global malaria campaign. We want to show how an

insect that we often consider annoying (the mosquito) is still the deadliest animal on earth. Mosquitoes take around half a million lives a year with just one tiny bite.

I think the film team have done an impressive job to bring that threat home along with the positive message that we can beat malaria. It is our oldest and deadliest enemy, which some experts say has killed up to half of all people who have ever lived.

Just let that sink in — by acting now, the ability to end the epidemic is within our reach.

Malaria is more than just a killer; it also disables. In many parts of Africa, it stops kids from going to school and cuts people’s salaries by around 25%. Often, it’s the poorest who are most affected.

Beating malaria will not only save millions of lives, it’s a no brainer on the financial front too. Every £1 invested in fighting malaria gives £36 back to communities and economies.

That’s a remarkable return.

How can you make a difference?

This month, 52 world leaders will arrive in London for a Commonwealth Summit hosted by the UK. With 90% of Commonwealth citizens living in countries affected by malaria, these leaders have an incredible chance to pave the way, change the course of history and save millions of lives by uniting to fight malaria. I am proud to be part of what I hope will be the biggest malaria event of the decade.

Tony Greenway

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FIGHTAGAINSTMALARIA.COM 9 PHOTO CREDIT: THE GLOBAL FUND / ANDREW ESIEBO

The challenge of preventing crossborder malaria transmission As countries across the world intensify efforts to stop the spread of malaria, collaboration across national borders has never been more important. In 2009, eight countries in southern Africa (Angola, Botswana, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe) committed to work together on a set of regional strategies that will complement the individual efforts of each country to achieve elimination.

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or a country to successfully eliminate malaria – and then prevent reintroduction of the disease – cases coming from neighboring countries must be detected, tracked, and treated immediately to prevent ongoing local transmission of parasites. That is a difficult task in southern Africa, where malaria is endemic and national borders are very porous. Infections are even harder to track and treat in regions where many people are considered mobile or migrant or live in rural, hard-to-reach areas.

The aim is to stop cross-border malaria transmission by facilitating collaboration among health ministers, national malaria programs, and partners across southern Africa.

This regional initiative uses an unprecedented approach that aims to accelerate elimination in the four low-transmission “frontline countries”—Botswana, Namibia, South Africa, and

Kelly Sibisibi Regional Analyst, E8 Secretariat

Kudzai Makomva Director, E8 Secretariat

Phelele Fakudze Policy and Advocacy Manager, E8 Secretariat

Swaziland—by 2020 and to pave the way for elimination in the four middle- to high-transmission “second line countries”—Angola, Mozambique, Zambia, and Zimbabwe—by 2030.

The ambition is to create a pioneering collaboration, which provides a blueprint for other countries and regions seeking to eliminate malaria.

Core objectives of the regional strategy include the promotion of regional coordination, high level advocacy, policy harmonisation, prevention of cross-border transmission, and sustainable financing.

southern African countries by 2030.

Member countries developed the Regional Malaria Acceleration Plan in 2017 as a regional roadmap that prioritises malaria investments to: 1) address interventions gaps in underserved communities that continue to drive transmission; and 2) provide a regional plan to leverage coordination, economies of scale, and collective action. By tackling the sources of malaria transmission and strengthening malaria prevention and surveillance in areas where imported malaria is likely, the Acceleration Plan sets the course for achieving the region’s elimination targets.

In an attempt to reduce the importation of malaria across national borders, we have established 46 malaria border posts (consisting of 33 border clinics and 13 mobile surveillance units). These are providing better access to malaria testing and treatment for migrant and mobile populations, as well as other underserved residents living in remote

communities along the borders. The posts are improving countries’ ability to identify infections, providing access to care and tracking areas of increased transmission.

In response to multi-country outbreaks in the region during the 2016/2017 transmission season, we are also enhancing epidemic preparedness and response (EPR) capacity at both the country and regional levels, and have established an EPR situation room to serve as a hub for monitoring regional epidemics as they occur, and launching a coordinated response. The situation room provides tailored support to national programmes in monitoring regional trends, troubleshooting response bottlenecks, and facilitating the incorporation of climate forecasting data.

Towards elimination by 2030 We are developing national malaria strategies with an aim to control and eliminate malaria.

With full view of the direction countries are moving, the initiative complements national malaria elimination efforts to ensure a well-coordinated platform for harmonisation of policies, strategies and interventions. This is key to achieving elimination across these

Read more on fightagainstmalaria.com

10 FIGHTAGAINSTMALARIA.COM

What is being done to rid Africa of malaria?

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Shrinking the malaria map The geological spread of this ancient and deadly disease has halved since discovery.

Professor Sir Richard Feachem looks at how far we have come.

His Majesty King and Ingwenyama Mswati III of the Kingdom of Swaziland Chair of the African Leaders Malaria Alliance (ALMA)

I

n my role, it’s important to continue work to rid the African continent of the scourge of malaria. Over the past 15 months, many African nations have developed a national malaria scorecard to track progress on malaria control and elimination. I think one major area that I want to work on, is the work to increase domestic resources for malaria and to accelerate the agenda on manufacturing pharmaceuticals in Africa.

How are you tackling malaria in Swaziland?

I am fully committed to a malaria-free Swaziland. Indeed, we have full operational coverage of vector control with mosquito nets and indoor residual spraying. I recently more than doubled our budget for indoor residual spraying and I increased the amount that we are spending on malaria programmes. We were the first country to institute a national malaria elimination scorecard to track our progress and according to WHO, Swaziland can eliminate malaria by 2020. We are doing everything possible to achieve this goal.

What are your priorities to eliminate malaria?

We are racing to meet the targets that we set. Top priorities are increasing domestic resources for malaria so that we can scale up and sustain universal coverage. We are working with the RBM Partnership to End Malaria to strengthen the national malaria scorecards and to establish national End Malaria councils.

Malaria knows no border, so we must collaborate across country and regional lines. We will also stamp out malaria increases where they occur and continue to address drug and insecticide resistance.

I hope to be celebrating our countries eliminating malaria in the coming years. We will achieve a malaria-free Africa!

eliminated in the early 1960s.

While it is true that temperate countries in general have eliminated before tropical countries, there are notable exceptions.

Most of the Caribbean islands elimIn 1897, when Ronald Ross and inated in the 1960s. Brunei, Singahis team in India discovered that pore, and Taiwan eliminated malaria malaria was transmitted by anoph- between 1965 and 1987. These are all eles mosquitoes, every country in tropical countries with previously the world had endemic malaria high rates of malaria transmission. In somewhere within its borders. The addition, while these Asian countries only exceptions were the Pacific are wealthy today, when they elimiIsland countries of Micronesia nated, they were not. When Singapore and Polynesia, where there are no eliminated malaria in 1970, it had GDP anopheles mosquitoes and there- per capita lower than Senegal today. fore no malaria.

Coming to the present day, the Malaria even occurred in the process of shrinking the malaria summer in the Russian port of map is accelerating. Five years ago, Murmansk, north of the Arctic Cir- Sri Lanka eliminated malaria. Chicle. Since that time, we have been na, for the first time in 5,000 years, progressively shrinking the malar- ended 2017 with zero local malaria ia map. Country after country transmission across its vast territohas achieved elimination, which ry and its huge population. means no transmission within Other countries are close to elimthe borders of that country. Of the ination. Botswana, Namibia, South roughly 200 countries in the world, Africa and Swaziland have committed half have eliminated; 19 since the to eliminate by 2020. While this may year 2000. not be achieved in all cases, these Shrinking the malaria map has gen- countries will be close and will cererally proceeded from north to south tainly eliminate soon after that date. in the northern hemisphere and Meanwhile, in Asia, Bhutan, from south to north in the southern Malaysia and Timor Leste are very hemisphere. Thus, Canada eliminated close to elimination and intend to before the USA, and Mexico is now finish the job by 2020. Ambitiously, completing the task of elimination. the entire Asia Pacific region, from Scandinavia eliminated before the Afghanistan in the northwest to United Kingdom, and the last coun- Vanuatu in the southeast, has comtries in western Europe to eliminate mitted to eliminate malaria by 2030. were Spain, Italy and Greece. SimilarIn large countries, shrinking the ly, in the southern hemisphere, Chile malaria map is a process that goes andV1_Layout Uruguay 1were the first23:55 to elimiGuardian 12/04/2018 Page 1on within the country. For example, nate in South America, and Australia Indonesia and the Philippines are

Professor Sir Richard Feachem Director, Global Health Group University of California San Francisco

eliminating province by province and progressively ending malaria transmission within their large and diverse territories. India is embarking on a similar process. The heartland of malaria in India is in states such as Madhya Pradesh and Odisha. While reducing malaria in those states is critical, an equal priority is to shrink the malaria map for India. In the south this means eliminating in Kerala and Tamil Nadu and then pushing north into Karnataka and Andhra Pradesh. In the northwest, this means elimination in Punjab, Gujarat, and neighbouring states and then pushing south into Maharashtra.

Some people ask why we should focus on elimination when most malaria deaths are in the high-burden countries in the endemic heartland.

Certainly, bearing down on malaria in the endemic heartland is a very high priority. However, at the same time, we must continue to eliminate progressively from the endemic margins inwards. This process of shrinking the malaria map will allow us to increasingly concentrate our efforts in the few remaining endemic countries where elimination will prove extremely difficult.

Accelerating the long standing process of shrinking the malaria map is an essential element of our global malaria strategy. When the malaria map has been shrunk to nothing, the whole world will be free from this ancient and deadly disease.

At Sumitomo Chemical, we are proud of the contributions we have made in the global fight against malaria, both on our own and in collaboration with other organisations.

Over the course of 16 years, we have delivered over 300 million nets to more than 80 countries worldwide, saving an estimated 600,000 lives and averting approximately 100 million cases of malaria1.

With more countries reporting resistant strains of mosquitoes to “classical insecticides�, Sumitomo Chemical is leading innovation to develop new modes of action to combat resistance.

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FIGHTAGAINSTMALARIA.COM 11

“There is no reason why anyone should die of malaria today” SPONSORED

Gains made in the fight against malaria are in danger of being lost because of insecticide resistance. The world needs to think again about how it is tackling the disease — and fast.

There’s no doubt about it, says Helen Pates Jamet, Global Head of Research and Market Access at Vestergaard; in the fight against malaria, the world is at a crossroads.

This is alarming when such significant strides have been made in tackling the disease for more than a decade. The use of long-lasting insecticidal nets is largely credited with reducing malaria cases in Africa by 68% and individual access to an insecticide-treated bed net has increased from 34% in 2010 to 61% in 2016. However, last year the World Health Organization (WHO) reported an increase in the estimated malaria cases worldwide.

The gains we have made over the last decade are now in danger of being wiped out.

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We must improve access to effective protection

Mikkel Vestergaard Chief Executive Officer

Helen Pates Jamet Global Head of Research and Market Access

WHO’s World Malaria Report 2017 reported an estimated 216 million malaria cases in 2016 — that’s an increase of around five million over the previous year — while deaths from the disease remained at a worryingly similar annual level (around 445,000 deaths globally).

“One of the main concerns — and one of the biggest challenges we face — is insecticide resistance,” says Pates Jamet. “We have been warning about the danger of insecticide resistance for years, and now the number of malaria endemic countries reporting resistance to pyrethroids — the chemical used on bed nets — has increased from 71% in 2010 to 81% in 2016. There is an urgent need to use newer, more effective tools.” Unfortunately,

the road to getting new products evaluated and to market can be frustratingly slow.

Vestergaard’s CEO, Mikkel Vestergaard, identifies another pressing need: the focus has to move from ‘coverage’ to ‘effective coverage.’

Take the bed net; a simple intervention: easy to give out, easy to use and designed to last for at least three years. “From a cost-effective point of view, nets are one of the cheapest ways on the planet to save a life,” he says. “But there’s no point in simply giving out millions of pyrethroid-only bed nets in areas with pyrethroidresistant mosquitoes. We need to ensure that more effective nets that actually kill resistant mosquitoes are used at scale.”

So, is Mikkel Vestergaard optimistic that malaria will ultimately be eliminated? “Well, first we need to get to the stage where no one is dying from the disease,” he says. And what’s particularly tragic is that the tools needed to achieve that goal are available right now.

“Sadly, they’re not getting to the right places at the right scale. But the fact is, there’s no reason why anyone should die of malaria today. So, let’s get to that point — and then we can talk about ‘malaria elimination’.”

Tony Greenway

More about Vestergaard: To combat the threat of insecticide resistance, Vestergaard continues to innovate the next generation of bed nets and partner with the private sector and multilaterals to distribute products, while making sure the company is part of the ongoing dialogue about fighting the disease. To further bolster scientific research, Vestergaard runs a vector research lab in Ghana in partnership with Noguchi Memorial Institute for Medical Research and developed an online tool (released in 2012) to map insecticide resistance.

4/4/18 8:51 a.m.

12 FIGHTAGAINSTMALARIA.COM

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The inconvenient truth about our battle against malaria Malaria-related deaths have increased by 100% in many countries across the central belt of Africa. We need to face some harsh facts, and change our approach to malaria prevention, fast.

Otherwise death rates will continue to rise.

The world must face an inconvenient truth in the fight against malaria, says Richard Allan. And it must face it now.

The inescapable fact is that the number of people contracting the disease — and dying from it — is rising. “Central African Republic, Chad, Congo... the incidence of people infected by malaria in places such as these has escalated dramatically and death rates have increased by 100%,” he says. “That’s extraordinary data.”

And incredibly worrying.

“The situation is dire” There have been malaria prevention success stories, of course. Two years ago, heartening statistics from the World Health Organization’s World Malaria Report showed impressive malaria reductions in 55 countries.

But there was a catch, notes Allan.

These countries only accounted for 4% of the total estimated malaria cases. “There were 97 countries where we had achieved little, and two years on, 80% of the world’s malaria cases are contained in a group of countries across the central belt of Africa, most, affected severely by humanitarian crises. The annual toll of malaria deaths in many of these countries has consistently risen since 2010,” he says. The situation is increasingly dire.

Allan is founder and CEO of The MENTOR Initiative — an organisation offering technical and operational support to deliver disease control to countries suffering from tropical diseases. He knows how people are suffering on the ground. He believes the organisations tasked with malaria prevention must fundamentally

reassess their approach. For example, he says, there’s a tendency to assume that if people in affected countries own mosquito nets then that will be enough to save their lives. Sadly — and invariably — it isn’t.

Nets are – sometimes – not culturally accepted “Nets protect you amazingly well if two things happen,” says Allan. “If the insecticide on them is effective; and if people sleep under them. We make the assumption that if we just keep giving out nets in vast volumes, those two things will be true.” Yet, too often, nets are distributed without effective insecticides; and checks are not being made to see if people are using them properly — or at all.

And anyway, nets are not the solution in every case, especially in countries where communities are displaced and living in temporary settings, says Allan. “For example, some houses or tents are unable to hang nets — perhaps they aren’t high enough or have no point of attachment — plus there are settings where nets just aren’t culturally accepted or used.” He stresses that other tools in the malaria prevention toolbox, such as larvicides, insecticide-treated tents, curtains and blankets, wall linings, indoor residual spraying with effective insecticides, and spatial repellents, should also be employed where necessary. “Integrating all these solutions — and then selecting the right ones for the right context — will yield far better results,” he says.

High-risk areas have less money to battle malaria Allan also believes there has been too much focus on countries where malaria is easier to control and where the fundamental burden of disease is lower. But what about those places where malaria is endemic and where infrastructure is poor or non-existent? Or where fragmented communities are at war with each other?

“The amount of money spent on malaria funding varies immensely,”

Richard Allan CEO, The MENTOR Initiative

The tools to make a difference to malaria prevention already exist. Unfortunately, getting through required regulatory processes is another, painstaking story.

he says. “Look at São Tomé — a country where many people would like to go on holiday. 16 dollars per person is being spent on malaria control there.

Then look at those countries where there has been a 100% increase in death rates from malaria since 2010, such as the Central African Republic, where the amount spent on control is about 40 cents per person.”

There is something fundamentally wrong with this mentality, says Allan. “The problem is, when you take the lower hanging apples off the tree, you are left with the truth,” he says. “And the truth is that the fruit on the harder-to-reach parts of the tree take up much more space — but we didn’t buy a ladder to reach it because we didn’t want to spend the money on it.”

The world currently has it backwards, says Allan: it should be spending 16 dollars per person on countries with the highest burdens of malaria, and 40 cents per person on those countries where control has been achieved in order to maintain the gains that have been made.

What must be done?

So, three critical things now have to change: 1. Investment in malaria control must increase; 2. Humanitarian organisations must partner with companies that have developed effective tools, with effective active ingredients that kill mosquitoes, and which are designed to suit to settings in the most malaria-prone countries; 3. And delivery of those tools has to be efficient, which means, for example, working with emergency agencies that are used to working in conflict zones.

Perhaps Dr Tedros Adhanom Ghebreyesus, Director General of the World Health Organization, summed it up best in the World Malaria Report 2017: “If we continue with a ‘business as usual’ approach

— employing the same level of resources and the same interventions — we will face near-certain increases in malaria cases and deaths,” he wrote.

“It is our hope that countries and the global health community choose another approach, resulting in a boost in funding for malaria programmes, expanded access to effective interventions and greater investment in the research and development of new tools.”

Change is too slow Allan wholeheartedly agrees with that assessment. Unfortunately, he says, altering the course of the institutions and bodies responsible for malaria prevention is like turning a supertanker.

“There is an entire administrative procurement system and policy setting system that takes years to change,” he says. “It has tuned itself to favour bulk buying the cheapest nets and is squeezing the good quality manufacturers out of the market.” A constant desire to get more for less can have lethal downsides, he warns. Take net durability, for instance. If a net becomes damaged, its effectiveness against mosquitoes is reduced, or even eliminated. The cheaper the net, the less durable the material.

Allan is confident that things can change, because the active ingredients and tools to make a difference to malaria prevention already exist.

Unfortunately, getting these through the required regulatory processes is another painstaking story.

“It took the World Health Organization almost 10 years to make insecticide-treated nets global policy after the evidence was published that they would dramatically reduce mortality,” he says. “So I am confident these changes will happen. I’m also confident, sadly, that they will happen too late for many.”

Tony Greenway

The map we have featured throughout this campaign represents the global spread of malaria since 1900.

This final page envisions successful malaria control and elimination by 2030, as proposed by the World Health Organization Global Technical Strategy for Malaria 2016–2030.