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Act today, tomorrow is too late: A rallying call to malaria research

17 Oct, 2013

Marta Tufet is an International Activities Adviser for the Wellcome Trust. She recently attended the Multilateral Initiative for Malaria meeting in Durban and shares some of the stark messages that came from the conference. 

Mosquito infecting with malariaOf my memories from the London 2012 Olympics, I remember most the clear sense of excitement and anticipation; the prospect of seeing our old favourites perform, discovering new uprising stars, meeting people from different countries coming specifically for the occasion, making challenging decisions about what events to prioritise. For malaria researchers across the globe, the Multilateral Initiative for Malaria (MIM) meeting, has a similar feel.

Held every 4 years, MIM is largest gathering of the malaria community, and in Durban, South Africa this year it brought together academic and industry researchers, clinicians, NGO workers, funders, policy makers, ministers, from all over the world to discuss one thing: what to do about malaria.

Prevention, treatment, control, elimination, were common words heard in corridors and tea breaks, in between the rush of young African researchers eager to put up their scientific posters or load their Powerpoint presentations to share their latest findings and show the world that they would be the next research leaders to solve Africa’s health challenges — welcome progress from the handful of young researchers in attendance at the first MIM meeting in 1999.

Among the new discoveries, we were privileged to hear some exciting news first-hand about how we are one step closer to the world’s first malaria vaccine, with GlaxoSmithKline potentially seeking regulatory approval for RTS,S as early as next year. The latest trial results showed that after 18 months follow up the vaccine cut the number of malaria cases by half and reduced malaria cases in infants by a quarter, which given the burden of malaria could have a significant impact.

Among the old favourites, was Professor Nick White from Oxford University and Mahidol University in Thailand. Only a few years ago White and colleagues in Africa, Thailand and the UK had astounded the community with the results of the AQUAMAT trial, showing that a 22.5 per cent reduction in mortality could be achieved by changing the standard treatment drug recommended for severe malaria — prompting the World Health Organisation to quickly revise its guidelines, saving hundreds of thousands of children.

This time White was not bearing good news. He warned that resistance to our most effective front-line drug against malaria has started to spread across Southeast Asia and will reach the African continent in no time unless radical measures are taken. Africa bears the highest burden of the disease so the effects of this would be devastating, with hundreds of thousands of young lives in danger. “It is Southeast Asia’s problem today, let’s stop it being Africa’s problem tomorrow,” he said, while the audience sat uncomfortably thinking about this looming threat.

W0039951 Vector control: insecticide-treated mosquito nets

Broadly speaking there are two approaches to fight malaria, we can prevent infection by avoiding mosquito bites (using insecticides and bednets) and we can treat infected people with available drugs. The upscale of these combined approaches in the past few decades has led to huge reductions in malaria mortality and morbidity (up to 50 per cent) in some countries in Africa. But these gains are under serious threat. Both the mosquitoes and parasites are also fighting back by mutating and adapting to develop resistance to insecticides and malaria drugs, respectively.

Over the past few decades we have watched our most valuable antimalarials rendered useless one after the other one. Resistance to chloroquine first originated in Southeast Asia in the late 1950s, proceeded to spread across Asia and finally to Africa in the following three decades, forcing many countries to abandon its use for the treatment of malaria. Likewise, resistance to pyrimethamine also emerged in the same area in Asia and spread even more rapidly to Africa. So it was really only a matter of time before resistance appeared to our last most effective frontline malaria drugs, the artemsinins.

Indeed, White, reported that, as with previous drugs, resistance to artemisinin originated in Western Cambodia and resistant parasites are now spreading westwards across Southeast Asia, making their way into Myanmar. With the increase in air travel and migration, once the resistant parasites conquer Myanmar, there will be no turning back, and spread to the African continent will be inevitable, with hundreds of thousands of children dying again from malaria.

Chloroquine

The drivers of resistance and drug tolerance are complex but it is clear that drug misuse is a major contributor. Inadequate dosing and the use of monotherapies (use of a single drug rather than in combination with others) are contributing factors, but more worrying is the use of substandard and counterfeit drugs, which are available in huge numbers — 50 per cent of all antimalarials being used in Western Cambodia were fake!

So what should we do? Should we just carry on strengthening our control systems? White presented robust scientific evidence that quickly convinced us that this was not enough and a more radical approach was needed, even if this causes discomfort among the international world.

We could consider mass drug administration, this may be operationally, politically and ethically challenging but could ensure that a firewall is created and the parasites are contained in Myanmar.  A stronger, more active voice from citizens may also help. There may be a need to inform communities so that in turn they can put more pressure on governments to address this threat. More research may be needed to determine exact dosages, but the development and distribution of counterfeit drugs is criminal and should be treated as such, with anyone contributing to this prosecuted accordingly. The issue of substandard drugs is a different story that may require more muscle force legislatively but should also be tackled. Finally, and most controversially, should we consider more stringent border control if it helps save lives?

Containment is feasible and if there were enough political will it could be done, but currently there is no such will. As an African proverb goes, “if you think you are too small to make a difference, then you haven’t spent a night with a mosquito”. Spread the word!

Marta Tufet, Wellcome Trust, International Activities Adviser

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