The world has yet to emerge completely out of the long shadow of Covid-19 but the hunt continues to find the most effective ways to eliminate a deadlier disease – Malaria – one that has grappled health experts globally for decades. There is hope on the horizon now with newer technologies and innovative approaches to vector control among other developments. On World Malaria Day, April 25, Dr Soumya Swaminathan, the chief scientist at the World Health Organisation (WHO) shared her insights on this crucial subject and on the way forward in an interview to the Indian Express Group. Here, we have Dr Corine Karema, a senior Malaria expert and the former Director of the Rwanda National Malaria Control Program (NMCP), who has been involved with the disease closely over the years, sharing her views in an email interview with The Indian Express Group’s E Kumar Sharma. She covers a range of issues, both for the globe and more specifically for India. Here are the excerpts:
In the context of this year’s theme for World Malaria Day – Harness Innovation to Reduce Malaria – how can Commonwealth countries best use innovation in each of these areas to end malaria?
Countries can adopt innovative approaches to partnerships and financing, adopt innovative tools, and take a targeted approach to delivering malaria interventions, improving supply chains, and strengthening surveillance and lab capacity. Importantly, the Covid-19 pandemic has reinforced how investing in real-time data is vital to effectively fight an infectious disease. Countries’ increased adoption of data-driven decision-making and tailoring approaches to optimise the use of malaria interventions to local contexts will help drive malaria cases and deaths back down in countries with a high burden of malaria.
There have been several recent scientific advancements made in malaria elimination, including vaccine candidates such as the RTS,S? Which of these do you think will reinforce India’s malaria elimination program most dramatically?
The RTS,S vaccine has been recommended as a complement to existing malaria prevention and control tools among children under five in sub-Saharan Africa and in other regions with moderate to high P. falciparum malaria transmission. However, countries will need to determine if and how RTS,S can complement their malaria control strategy by evaluating a range of considerations.
However, there is no ‘one size fits all’ approach to ending malaria. It is still important that countries continue to scale up a range of existing, complementary tools – such as long-lasting-insecticide treated nets, indoor residual spraying and preventive treatment – to save more lives, strengthen community health and make the best use of limited resources.
India is already making impressive gains against malaria with existing tools. It reported the largest reduction (60%) in confirmed malaria cases in 2019 compared to 2017 and is one of the few high burden countries to demonstrate a significant decline in malaria cases, largely due to commendable commitment in the highly affected state of Odisha.
Your thoughts on how to fine tune an integrated vector control operation when the problem is in select pockets, as is the case with India?
It is vitally important that India continues to increase adoption of data-driven decision making and tailoring approaches to optimise the use of malaria interventions to local contexts. This approach is crucial to maximize resources available to fight malaria and drive down malaria cases and deaths.
However, success against malaria also requires country and community ownership of the fight against malaria. Community voices and action – including among younger generations – must be celebrated and amplified at the local, regional and global level. It is critical that individuals hold leaders accountable to their commitments – whether through speaking to their local leaders, using social media, or calling for increased public and private funding to expand access to life-saving tools.
What are some of your suggestions to have a very effective surveillance system and response mechanism in place?
Frontline workers are increasingly adopting digital tools to report into disease monitoring systems and these digital tools have proved critical during the Covid-19 pandemic. When fully integrated, these surveillance systems are often sustainable and cost-effective.
To scale up these tools, countries must leverage domestic resources to make investments in innovative and effective digital solutions at the point of care. Of course, India already has a wonderful track record for developing digital software in the private sector, and these capabilities could also be applied to create surveillance solutions to fight diseases like malaria.
Your recommendations on manpower training and dealing with challenges when there is shortage of entomologists?
Entomology is important to fight a wide range of diseases, including malaria. India has a strong track record in vector control entomology, particularly for other vector-borne diseases. A wise solution would therefore be to build research institutions’ capacity to leverage expertise across a range of vector-borne diseases including malaria, dengue and neglected tropical diseases.
Any thoughts on how to combat drug and insecticide resistant malaria?
In recent years, antimalarial resistance has been observed in the Greater Mekong Region and in some parts of Africa, and insecticide resistance is also a global threat. The malaria parasite and the mosquito that carries it are constantly evolving to evade our efforts to curb the disease, which means there’s a risk our existing tools will become less effective over time.
The World Health Organization has developed guidelines to help countries mitigate, monitor and respond to resistance to these tools. In areas where resistance has spread, robust surveillance systems and strategies are critical. For example, genetic disease monitoring systems with improved parasite and mosquito genetic sequencing can track the emergence of resistance to new and existing tools in close to real-time and are being trialled in countries with support from the Global Fund. Rotating the insecticides used for Indoor Residual Spraying campaigns is another key strategy for preventing insecticide resistance.
Scientists are constantly innovating to develop new insecticides and treatments to counter this challenge. For example, initiatives such as the New Nets project, supported by the Global Fund and Innovative Vector Control Consortium, are working to create next-generation nets which use different combinations of insecticides for use in areas with mosquito net resistance. Last month, for example, a research study found that Interceptor G2 dual-insecticide nets reduced cases of malaria by over a third compared to nets with just one insecticide, and the introduction of Pyrethroid-PBO nets has also proved effective. Tafenoquine, a new treatment for P. Vivax malaria (the most common cause of the disease in India) was also approved for use by the Australian Therapeutic Goods Administration earlier this year in combination with chloroquine. In the longer-term, we must also prioritise developing transformative tools that can be game changers in the fight against malaria.
Individuals and communities must also play a role by using interventions appropriately. To mitigate drug resistance, patients should seek a diagnosis to confirm cases of malaria before taking any medicine and ensure they are fully compliant with the recommended course of treatment. The availability of counterfeits and sub-standard drugs on the market also increases the risk of resistance, so communities should be vigilant (in addition to national monitoring and regulatory control measures).
Disruptions in malaria services delivery during the Covid-19 pandemic meant that the world was unable to deliver on the 2020 goal to ensure 40 per cent global reduction in malaria mortality and cases. Your thoughts on what needs to be reprioritised to ensure we move fast and recover the lost ground?
While the Covid-19 pandemic was disruptive, it is also important to recall that countries mobilized to sustain more than 90 percent of mosquito net and seasonal malaria campaigns, through unwavering commitment and by adopting innovative approaches to ensure campaigns were delivered in time.
We have seen how countries have come together to address the pandemic, to pool resources and take action to reach a common goal. Malaria is no different. We require a combination of high-level political support, more funding, the involvement of the private sector, and community ownership to achieve a malaria-free world.
What are some of the successes from Global Fund and RBM Partnership’s response against Covid-19 that malaria programs can take away from?
Throughout the Covid-19 pandemic the RBM Partnership to End Malaria has worked closely with the Global Fund, the US President’s Malaria Initiative and national governments and partners to use real-time data to prevent shortages of life-saving medicines and rapid diagnostic tests.
These efforts helped to minimise the impact of the pandemic on malaria prevention and treatment campaigns and I hope they will be maintained long after the pandemic to help countries make informed decisions to have a greater impact against malaria.
Given the overall increase in malaria cases and deaths globally, what should governments, especially in high-burden countries, focus on to ‘build back better’?
The pandemic has shone a light on the weaknesses in our health systems and as they build back better after the pandemic, governments should focus on building strong and resilient health systems that are fit for purpose. Investments in building resilient health systems and scaling up community health services will not only help build capacity to detect and respond to future health threats, but these are also fantastic investments that allow us to better fight existing diseases like malaria.
What are some of the measures the RBM Partnership is planning to support high burden countries on the path to elimination?
We know that countries and communities are at the centre of an effective malaria response. Since 2018, the RBM Partnership and the World Health Organization have been working with 11 high-burden countries – including India – to implement the High Burden to High Impact approach. This country-led approach supports countries with a high burden of malaria to better target malaria interventions district-by-district to maximize impact and make the best use of limited resources to address the challenges and epidemiological context specific to each district.
We are also dedicated to supporting countries to take a multisectoral approach, bringing together different stakeholders at the national and subnational levels to align strategies and maximize resources – and ultimately accelerate progress against malaria.
Malaria continues to take its heaviest toll on the world’s poorest and most vulnerable people, and through our efforts to end malaria we also hope to achieve a more equitable world. For example, in 2018, in partnership with The Global Fund, we piloted the Malaria Matchbox tool in India and Niger, providing guidance on how to identify risk factors and barriers impeding equitable and integrated people centred malaria programs, included gender-related barriers.
China went from reporting 30 million cases in the 1940s, to zero cases by 2021. Other countries, such as Sri Lanka, Argentina, and El Salvador (2021) have also been granted malaria-free status? What could we learn?
There are several tried-and-tested strategies which have proved successful among countries which have eliminated malaria in recent years. Firstly, to drive down cases of malaria, countries require ongoing commitment and investment to ensure that everyone at risk of malaria is reached with life-saving tools. Tailoring malaria control strategies to local contexts has also proved successful for many countries.
For countries approaching malaria elimination, cross-border collaboration is critical to reduce the risk of malaria-carrying mosquitos crossing borders with neighbouring countries, as well as investing in malaria surveillance and taking a targeted approach to ensure every single remaining case of malaria is reported and treated.
The Covid-19 pandemic has underscored the need to be prepared for future health threats while we eliminate existing ones. Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) supports malaria control in several other countries worldwide (including India). How critical is the replenishment of the GFATM, which called on the world to mobilize US $18 billion to save 20 million lives?
The Global Fund accounts for more than half of global funding for malaria programmes, so its importance cannot be underestimated. By achieving the Replenishment target of at least US$18 billion, the Global Fund estimates these investments can reduce cases of malaria by 66%, cut malaria deaths by 62% and eliminate malaria from at least six countries by 2026, bringing us closer to a malaria-free world.
However, we are now at a precarious juncture and a lot is at risk if countries do not achieve this goal. New data suggests the global malaria burden is higher than previously estimated, the Covid-19 pandemic has disrupted malaria control efforts, and emerging threats such as insecticide and drug resistance and even climate change risk the progress we have made over the past 20 years.
Such investments are not only crucial to accelerate the fight against malaria, TB and HIV/AIDs; they are also at the heart of countries’ efforts to strengthen health systems, be prepared for future pandemics, and even reduce inequalities. Zero Malaria starts with all of us – everyone, everywhere must come together this year to fight for what counts and ensure we achieve a fully replenished Global Fund!
Dr Corine Karema is a malaria expert and former Director of the Rwanda National Malaria Control Programme (NMCP). She has also been head of the Malaria & Other Parasitic Diseases (Neglected tropical diseases) Division – Rwanda.
(The above article is for information purposes only and is not intended to be a substitute for professional medical advice. Always seek the guidance of your doctor or other qualified health professional for any questions you may have regarding your health or a medical condition.)