Bridging the Malaria Gap: Lessons from the Field

[This blog is part of the #DefeatMalaria World Malaria Day blog series hosted by Roll Back Malaria, to be published between April 8 and May 1, 2015]

As we draw our collective breath, the malaria community can surely bask in the knowledge that the malaria landscape has shifted enormously since the year 2000.  Almost every tool that we are using today was introduced since then:  Long lasting, insecticide treated bednets, a new insecticide, rapid diagnostic tests, as well as Artemisinin-based Combination Treatments (ACTs). 

It is a testament to the drive for making the country efforts more effective that innovation has been a key element of the global program.  Today, along with great progress in decreasing malaria deaths and cases being witnessed in 2015, the malaria community is facing problems that require innovative tools as strategies, as well as resources to use them.

At this point, investments in basic research and product development over the past 15 years has yielded a robust pipeline of candidate drugs and vaccines, mosquito control tools (classical and really novel approaches), and the promise of improved diagnostics that will readily identify those who are harboring the parasite but not yet ill.  Public – private partnership in product development have been extremely productive.

And not a moment too soon – as data filters in from the field, we are acutely aware of the possibility of increasing resistance to artemisinin – the lead drug class in combination therapy, as well as pyrethroids – at this point, the only insecticide class on long lasting bednets (LLINs).  Combination therapy to avoid the generation of resistance, good quality drugs, and completion of the three-day treatment regime may have slowed but has not prevented resistance emerging in Asia.  Similarly, combination use of Indoor Residual Spraying with LLINs, effectively gunning the mosquito down with two different insecticides, has left us with a distribution of markers of resistance that is now being examined for linkage to worsening performance in the field.

That has been the very long history of malaria:  the parasite has successfully co-evolved with humans, and its tremendous plasticity allows it to eventually overcome both treatment and prevention.

What then, are we left with? 

First, we are getting smarter – and can hope to outrun the parasite.  By targeting elimination using both emerging tools and emerging strategies to use those tools, countries that can reach zero transmission – hereby eliminating the parasite from their population – increasingly find that they can manage the occasional reintroduction.  Even the US has several hundred cases of malaria reported every year, but has the systems to find the cases and stop further transmission.  Health systems matter, not only to stop transmission, but to effectively manage the post-elimination cases.

Second, we need to sustain the integration of innovation to the future malaria program.  This applies to tools such as better drugs that can overcome resistance, but also be effective in a single dose – two very different kinds of innovation.  More difficult to see is that this culture of innovation has to reach down to implementation.  One example is the need for the best implementation science to give us the evidence on new ways to use drugs to achieve both individual and public health goals.  Population-level drugs (mass administration) and vector control (LLINs and/or IRS) have been used in combination in various permutation s over the past century.  However, programs were often poorly designed and documented, reflecting both older methods, as well as less attention and financing to abstracting the lessons from the field.   

Third, there is value in knowledge management, not just when results are published.  Today, a variety of projects on population level use of drugs in combination with diagnostics, mosquito control and through mapping of disease are ongoing.  When the field comes together to share methods, design and outcomes, there are three potential benefits:  first, the results are comparable across sites; second, there are potential efficiencies with less unnecessary repetition of the same projects, and third, there is the potential for increased speed of translating good ideas into country programs.  All of these are critical to the impact of the global effort.  Countries need to learn from each other.  Donors seek efficiencies in achieving impact, so that a strategy that is cheaper or more effective can be prioritized. 

In the longer term, how to use existing and new tools most efficiently will decrease the costs of the global malaria strategy towards elimination.  Important when we have at best half the resources needed!

One problem is that there are relatively few sources for funding of implementation science in malaria, in all of its varieties.  The largest program funders, such as UK and USA, do make these types of investments in solving some of the problems they are facing in the field. The Global Fund for AIDS, TB and Malaria, has had important replenishment of funds, but its board has not allowed it to make direct investments in improving the efficiency of its programs.   At heart is the perceived competition between yet unfunded  program elements and research which may appear to be less directly applicable to health impact.

 Aside from funding is the knowledge management challenge:  how funders and researchers can be aware of what is being funded up front, rather than waiting years later for publication, and how to disseminate results rapidly, particularly to decision makers.  One example is a simple web based tool has been created by the Malaria Eradication Scientific Alliance (MESA Track) to track active projects and facilitate sharing of early results.

Ultimately, if we are to tackle any form of long range, sustainable solution for malaria, research to create and integrate new tools, streamline surveillance-response, and increase impact at a decreasing cost, needs to be integral to how we are tackling malaria, with robust country feedback from country experiences as to priority areas.  

[Regina Rabinovich is the Director of the ISGlobal Malaria Elimination Initiative and ExxonMobil Malaria Scholar in Residence at Harvard University. She also chairs the Malaria Eradication Scientific Alliance (MESA) Steering Committee].