On World Malaria Day 2015, Allan Schapira and Lorenz von Seidlein discussed the accomplishments and challenges of the fight against malaria.
Lorenz: Is there much to celebrate on World Malaria Day 2015?
Allan: Well, in 2000 we estimated there were roughly 801,000 malaria related deaths in Africa. In 2014 we estimate that this number had dropped to 528,000 malaria deaths.
Lorenz: 528,000 malaria deaths are really nothing to celebrate. That is a lot of misery.
Allan: Indeed, but the malaria mortality rate in Africa has decreased by more than 50% ¹ over less than 15 years – that’s an epic achievement, but certainly not enough. I find it striking that the number of ACT courses procured in the world in 2013 was as high as 392 million courses, while the estimated proportion of all children with malaria who received ACTs was estimated at only 9 to 26%.
Lorenz: 74 to 91% of children with malaria are not treated. Again there is not much to celebrate.
Allan: The first problem to deal with is the unsatisfactory and slowing decline in malaria mortality in Africa. While there is room for improvement of ITN coverage, the priority should be to scale up access to early effective treatment including improved care-seeking. There is always scope for cost-effectiveness studies and comparisons of private and public approaches, the surest and most rapid way to reduce malaria mortality is a massive scale-up of community case management of childhood illness (CCM), which will also help reduce pneumonia and gastroenteritis mortality. It will also strengthen health systems, which is now better understood as a priority, as the international community is trying to deal with Ebola. CCM is still conducted as a pilot activity. Why has it not been mainstreamed?
Lorenz: Totally agree. But what can the most dedicated village health workers achieve if the drugs no longer work? We are quite worried about the spread of multidrug resistance, no longer just artemisinin resistance. If the current first line treatment no longer works the reduction in malaria deaths could be quickly reversed. We could return to a malaria burden just like in the 1990s especially in sub-Saharan Africa.
Allan: Malariologists are fascinated with both drug and insecticide resistance, but these issues are receiving too much attention internationally compared to the mundane, managerial actions, which could rapidly lead to scale up of CCM and ITN coverage in Africa. As things are, the disaster is not going to be the spread of artemisinin resistance in Africa: The disaster is there, in the village, every day, where people, 37 years after the Alma-Ata declaration, 17 years after the start of the RBM mobilization, do not have access to basic services, resulting in some 500,000 malaria related deaths every year.
Lorenz: ITNs and case management with ACTs have been rolled out over the last 15 years and probably played a major role in the reduced global malaria burden. But just handing out more and more bednets is not the solution. There is the problem of insecticide resistance you mentioned and more worrying people really use their bednets for fishing. 87% of respondents along the shores of Lake Tanganyika admit to using their nets for fishing. They are also noticing that fish supplies are dropping perhaps to overfishing with fine mesh nets. Have we reached oversaturation with bednets in some places while other areas remain underserved?
Allan: I doubt whether this would have been addressed by sending fewer nets to that area: The problem seems to be that malaria is a smaller problem for them than hunger. There is a little bit of comfort in realizing that most people receiving LLINs do not live close to fisheries. The fact that malaria is less important than hunger from the viewpoint of some of the affected populations is really the fundamental factor, which is going to make any elimination effort, whether in SE Asia or in Africa, an uphill battle, isn’t it?
Lorenz: Let’s talk about recent developments which could accelerate malaria elimination. There is substantial financial support and surprisingly WHO support to add mass drug administrations to the existing control techniques when malaria has to be eliminated or at least reduced rapidly. MSF pulled off a massive mass drug administration treating more than a million people in Sierra Leone in the context of the Ebola epidemic. We want to use a similar approach in the greater Mekong Subregion (GMS) to eliminate multidrug resistant P. falciparum strains before they have a chance to replace the susceptible strains.
Allan: The mass treatment schemes with antimalarials in Ebola affected areas were brilliantly conceived to deal with a health emergency. They had nothing to do with elimination. The mass treatment projects proposed on the fringes of malaria transmission in Africa have no chance of achieving any lasting results except in certain island countries and possibly in places like Swaziland or Namibia, but such advances are minute and peripheral in relation to the continent’s malaria burden with no implications whatsoever for eradication. The proposed mass treatment schemes in Southeast Asia as part of a sub-regional elimination strategy have much greater potential, but the risks are also greater, especially if the public is led to believe that mass treatment is the only solution. And then there is the vaccine…
Lorenz: The final results of the large multicentre RTS,S/AS01 trial were published on World Malaria Day. Protection is better in older children vaccinated at age 5 to 17 months compared to the younger children who were vaccinated 6 to 12 weeks of age. In the older children the overall protection was 32% with a booster dose, but in the younger children there was no statistically significant protection. The booster dose at month 20 provided a brief boost but then protection waned again. The authors feel the vaccine prevented a “substantial number of cases” and has “potential to make a substantial contribution”. The trial is quite an achievement but the results are sobering. The vaccine protects a third of the vaccinated children for up to 4 years. There may be a role for RTS,S/AS01 in emergencies when short term protection is desirable, perhaps this is useful for tourists or soldiers, but as a childhood vaccine?
Allan: Personally, I think RTS,S/AS01 could have a role as a childhood vaccine provided the introduction is carefully monitored, as there are still important unanswered questions. The concern is that if it were licensed as part of a childhood vaccination programme, there might be less commitment to other essential interventions. RTS,S seems to have some effect in reducing the risk of infection in the short term; it really should be investigated as a component of an elimination strategy in low transmission areas.
Lorenz: Not much to celebrate then on world malaria day 2015?
Allan: I agree, but there are achievements that many stakeholders can and should be proud of. Anyway – let’s talk again next year….
Allan Schapira has worked for over 30 years on malaria and other issues in global health. A substantial part of this time he spent working with WHO and still serves as a consultant from time to time.
Lorenz von Seidlein has also worked for 20 years on malaria and other issues in global health. Lorenz is currently coordinating a major offer to eliminate malaria from areas with artemisinin resistance with the Mahidol Oxford Research unit In Bangkok, Thailand.
- Malaria statistics are from the WHO World Malaria Report 2014.