Malaria Is Evolving—Our Response Should Too

By guest contributors Christine M. Bachman and Dr. Kavitha Saravu

In the past decade, we’ve seen real progress in malaria control. New countries have achieved elimination status, malaria-attributed mortality has declined, and two WHO-prequalified vaccines—RTS,S and R21/Matrix‑M—are being rolled out across the continent of Africa. These are real gains. So too is the rise of African-led pharmaceutical manufacturing, like Kenya’s Universal Corporation Ltd, which now produces SP-AQ for seasonal malaria chemoprevention. But even as tools advance, malaria continues to shift—and our response must shift with it.

Africa remains the epicenter of the disease: 94% of global cases and 95% of deaths occur on the continent. Children account for nearly 80% of malaria deaths. Meanwhile, global case counts are climbing—263 million in 2023, up 11 million from the year before. This is no time to become complacent.

We are in an era where the parasite, the vector, and the environment are all changing faster than the tools designed to control them. Malaria is evolving. Our approach should be too.

Evolving Parasites, Lagging tools

One major concern is diagnostic reliability. While rapid diagnostic tests (RDTs) have been foundational in detecting Plasmodium falciparum, HRP2/3 gene deletions are spreading—first documented in Peru and now found in Nigeria and South Sudan. Without this key biomarker, many RDTs fail to detect infection. Microscopy remains an alternative but requires trained personnel, reliable power, and equipment access, which many rural clinics lack.

Drug resistance is also growing. Artemisinin combination therapies (ACTs) remain the gold standard for P. falciparum malaria, but partial resistance related to kelch 13 mutation is spreading across the East and Horn of Africa.  While ACTs’ still clear most infections, warning signs are mounting. Partner drug resistance- lumefantrine in East Africa and piperaquine in South America – further threaten ACT efficacy and increases the risk of treatment failure.

Meanwhile Plasmodium vivax poses distinct and growing challenges. Long overlooked in Southern Africa, Pv is gaining attention due to better surveillance and diagnostic tools. However, current RDTs have lower sensitivity for Pv, leading to underdiagnosis and missed treatment. Pv also forms dormant liver stages (hypnozoites) that can reactivate weeks or months later, fueling ongoing transmission.

Radical cure for Pv requires a 14-day course of primaquine, which is often abandoned once symptoms resolve or is avoided altogether due to risks in people with G6PD deficiency. Tafenoquine offers a promising single-dose alternative, but it too requires quantitative G6PD testing, which remains limited in many settings. Chloroquine (CQ) resistance in Pv is also emerging in parts of Asia and Latin America. Although ACTs are effective against both falciparum and vivax, growing partner drug resistance and drug pressure warrant careful stewardship. Some recommend continuing CQ where Pv remains sensitive to help preserve ACT longevity.

Even longstanding interventions like insecticide-treated nets (ITNs) are facing headwinds. Resistance to insecticides is rising, and behavioral use of ITNs remains inconsistent. Climate change adds another layer of uncertainty, altering mosquito behavior and seasonality. It’s no longer safe to assume mosquitoes only bite at dusk or in rural areas.

Perhaps the most concerning shift is the emergence of Anopheles stephensi, a vector capable of thriving in both urban and rural settings and active across seasons. Its spread into Africa disrupts long-held assumptions about malaria transmission and demands a major rethinking of surveillance and vector control strategies.

Beyond Breakthroughs: Delivering for Context

There are bright spots. RTS,S and R21 are promising vaccines, especially for children under five, and several countries—including Ghana, Kenya, Malawi, Cameroon, and Burkina Faso—have begun rolling them out with Gavi support.

But we must be clear: a vaccine is only as effective as its delivery system. Pricing, supply constraints, multi-dose schedules, and operational complexity all challenge rollouts. Efficacy, while meaningful, is not perfect—and vaccines must be integrated with other interventions. Above all, sustained community and health system buy-in cannot be taken for granted. These are powerful tools, but not silver bullets.

Progress toward elimination continues, though slowly. Suriname was just declared malaria-free, and Cape Verde recently earned WHO certification. Since 2015, only a handful of countries have reached this milestone. Achieving elimination takes more than commitment; it demands robust systems for cross-border surveillance, detection of asymptomatic carriers, and rapid response to imported cases.  

Yet the tools to support these efforts are still lacking. Most diagnostics are not sensitive enough to detect low-density or asymptomatic infections. Serological approaches hold promise, but current biomarkers lack the necessary specificity. Without more effective tools and systems, elimination will remain aspirational in most high-burden settings.

What Comes Next

We are at an inflection point. Climate, conflict, and migration will continue to shift where and how malaria spreads. Vectors are adapting, parasites are mutating, and health systems are under pressure. The challenge is no longer just developing better tools—it’s using them better.

This means:

• Embedding trials and delivery into local care systems, not standalone campaigns.
• Investing in data systems and diagnostics tailored to specific species and populations.
• Scaling African-led manufacturing to improve responsiveness and resilience
• Treating elimination as a multisectoral, sustained effort, not a donor-driven project cycle.

As malaria evolves, so must we. Precision, adaptability, and partnership will define the next era of control—and with the right focus, elimination is still within reach.

About the authors

Christine Bachman is a clinical research strategist focused on advancing global health innovation through evidence generation, regulatory alignment, and cross-sector collaboration. Her work spans diagnostics, infectious diseases, and health equity across Africa, Asia, and Latin America. Connect with her on LinkedIn or at www.chrisbachman.com.

Kavitha Saravu is Professor and Unit Head of the Department of Infectious Diseases at Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India. Dr Saravu is a clinician scientist with research interest in Infectious Diseases epidemiology, host pathogen interactions of tropical infections such as malaria, scrub typhus, KFD and tuberculosis. Connect with her on LinkedIn or email.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.