An Anopheles stephensi mosquito shortly after obtaining blood from a human (the droplet of blood is expelled as a surplus). This mosquito is a vector of malaria, and mosquito control is an effective way of reducing its incidence. (https://en.wikipedia.org/wiki/Malaria#/media/File:Anopheles_stephensi.jpeg)
What the Latest Data Tells Us About The Global Fight Against Malaria
On December 8, the World Health Organization released its latest annual report on the global fight against Malaria.
The World Malaria Report found that progress against malaria has begun to stabilize after COVID related setbacks. Specifically, after a sharp rise in global malaria deaths during the first year of the pandemic, deaths have now begun to decrease — though not yet to pre-pandemic levels.
In this episode we are joined by Martin Edlund, Chief Executive Officer of the non profit organization Malaria No More, to explain what this data shows about humanity’s progress against malaria. We discuss the impact of the COVID pandemic on the fight against malaria before discussion the broader landscape in which malaria is evolving to become a more resilient foe. We also discuss exciting technological innovations that may enable humanity to reach the goal of reducing malaria cases and deaths by 90% by 2030.
What Did Malaria Numbers Look Like Right Before the COVID-19 Pandemic?
Martin Edlund [00:00:00] The upshot is we need to continue to innovate. We’re in a constant arms race with nature in deploying these tools, both in terms of insecticides and the drugs that we use to treat the parasite. You know, if you look back over the last 15 years, Mark, we’ve seen historic progress in the malaria fight. What we’re talking about here is really humanity’s oldest, deadliest disease, something that you can find in the fossil record 20, 25 million years ago, and something that by many estimates, has killed more human beings than any other cause on the planet. And yet, in the last 15 years, we’ve seen remarkable progress. So, since the year 2000 we’ve saved nearly 12 million lives, prevented 2 billion cases of malaria; unlocked about $2 trillion in economic benefits for some of the poorest communities on the planet. In that time, 21 countries have eliminated malaria, so gone from annual transmission to no malaria whatsoever. And, you know, it’s because we have had really simple cost-effective tools, things like insecticide treated bed nets, rapid diagnostic tests, a $1 full course of treatment that if you get it, you do not die from this disease. And the combination of those effective tools and the progress we’ve seen have really led the world to recognize malaria as arguably the single most cost-effective way to save a human life on the planet by preventing people from getting malaria. So, the effective altruism movement, donor countries and certainly endemic countries have prioritized this as a way to save lives and improve livelihoods in their countries.
How has COVID affected the fight against malaria?
Mark L. Goldberg [00:05:08] So things were trending well for the last 20 years, then in 2019 and 2020, 2021 COVID hit, and based on the interviews I’ve done over the years, COVID interrupted a lot of progress on a variety of global health and development indicators. How did COVID impact the fight against malaria?
Martin Edlund [00:05:35] So, as in so many other areas, COVID was hugely disruptive to the malaria campaign. There were actually concerns right at the outset of COVID that you might see a doubling of deaths from malaria due to COVID disruptions. The concerns were that these massive distribution campaigns each year, about 200 million insecticide treated bed nets are distributed, that those would be disrupted due to supply chain issues and workforce issues. One of the other big concerns, of course, was that COVID is a febrile illness — you show up with a fever as the first symptom — so is malaria, and we’ve seen in cases like the Ebola outbreak in West Africa, that when there’s a novel disease that looks like malaria, people stop showing up to get tested and treated. They don’t want to be infected. They don’t want to be quarantined. So, there was a huge risk that you’d see testing and treatment rates fall dramatically. And so those concerns kind of spurred the malaria community and campaign into action. The good news is we managed and mitigated many of those risks. So, of the bed net distribution campaigns that were planned in the early months and the first year of COVID, about almost 90% of those went ahead as planned, so we were able to get the nets out. We actually saw initially some pretty troubling statistics on declines in testing and treatment rates for malaria, particularly in high burden settings like Nigeria, which is the single highest burden place for malaria in the world, but also kind of large population centers like India. And the good news is, over the last 18, 24 months, we’ve really reestablished high levels of fever testing and treatment. You know, in many ways, it’s taken some time. It’s taken a lot of work and heroic efforts by everyone from donors stepping up to frontline health workers taking the risk to deliver these interventions, but we’ve stabilized the effort post COVID.
Why have malaria deaths increased in recent years?
Mark L. Goldberg [00:07:32] Yet the progress that you are seeing, at least according to data reported in this newest World Malaria report, seems to indicate that indeed, over the last few years, progress stagnated, deaths increased.
Martin Edlund [00:07:48] They did indeed. So, for the second year in a row, for the first time since this global campaign began 15 or so years ago, we’ve seen malaria cases increase. And COVID certainly played a role in that, but I think COVID arrived at a time when progress was fragile and stalling anyway. And so, what we’re seeing in the malaria campaign, I think, first of all, is where we get these highly effective tools out, we continue to see gains. So, every year that we sustain these efforts, more than a million lives are saved. More than 185 million malaria cases are averted. So, the tools work when we get them to the people that need them most. But we’re seeing some challenges. There are still huge gaps in coverage. Almost a third of people aren’t seeking testing and treatment when they have a fever. An even higher percentage of people don’t have access to a mosquito net to sleep under on a nightly basis. And then there are new challenges, emerging challenges. For instance, drug and insecticide resistance are beginning to erode the effectiveness of these tools that we describe. We’re also seeing that malaria really thrives on chaos. It thrives on disruption. So, any time you have conflict or climate related severe weather events, malaria resurges, and we’re seeing growing evidence of that.
What are the key findings of the World Malaria Report 2022?
Mark L. Goldberg [00:09:13] And so this newest report seems to provide some evidence that a confluence of factors, displacement by natural or manmade causes, climate change, conflict, all are contributing to the latest data in this report. What are some of your key topline takeaways from the World Malaria Report?
Martin Edlund [00:09:38] Several things: one, I would say we’ve stabilized the effort since the onset of COVID, so cases did rise again, but deaths didn’t rise this year, in fact, deaths declined slightly. So, in 2021, they estimate that there were 619,000 deaths from malaria, down from 625,000 the year before. So that’s great. At the end of the day, our vision and our goal are to stop people dying from mosquito bites.
Where is malaria most deadly?
Mark L. Goldberg [00:10:06] So basically, as you said, you know, for the last 15 years, generally speaking, deaths declined. Then COVID hit, deaths started to increase, but now this latest report, you’re showing that deaths are stabilizing and even slightly on the decline once again.
Martin Edlund [00:10:23] That’s right. So, cases rose for a second year in a row, but deaths have declined slightly in the past year. So, another lesson from this World Malaria Report is that malaria is increasingly heavily concentrated in a small number of countries. So, 95% of cases, 96% of deaths are in sub-Saharan Africa, and in fact, 50% of all deaths from malaria globally are in just four countries: Nigeria, D.R., Congo, Uganda, and Mozambique. We continue to see gaps in access, as we talked about a moment ago. Net coverage isn’t where it should be; testing and treatment rebounded, but still one third of people, children with febrile illness in sub-Saharan Africa, don’t seek any timely testing or treatment for their illness. One bright spot in the report: there’s an intervention called seasonal malaria chemoprevention. So that’s a mouthful, but essentially what we’re talking about is at the onset or just before the arrival of the rainy season or the monsoon season, you do drug-based treatment and try to eliminate the parasite in the population and give people some prophylaxis, some resistance against infection.
What is seasonal malaria chemoprevention?
Mark L. Goldberg [00:11:41] And is this a relatively new intervention?
Martin Edlund [00:11:45] No, it’s something they’ve been testing for a while, but it’s really gone to scale in recent years. So, in the last year, covered by this World Malaria Report, 45 million children were treated on average with seasonal malaria chemoprevention in 15 African countries, and that’s up from about 33 million a year before, 22 million the year before that. So, we’re seeing big increases and particularly in some of those high burden countries that we talked about, places like Nigeria, Uganda, Mozambique. These are some of the countries that are benefiting most from this intervention.
Does malaria affect rural or urban populations more?
Mark L. Goldberg [00:12:19] And in those countries, Nigeria, DRC, Mozambique, and Uganda, are you seeing a distribution of cases and of deaths that skews largely rural, or is this also something that you’re seeing impact urban populations as well?
Martin Edlund [00:12:36] I mean, historically, malaria is often talked about as a disease of the rural poor, and that’s because that’s where it’s most tropical; that’s where you see standing water; that’s where you see people working in agriculture, in forested areas that are most conducive to mosquitoes and therefore malaria. You know, a number of cities are in tropical areas where you see transmission. One of the challenges that we need to solve for is testing and treatment in urban settings and in the private sector. Nigeria and Uganda, two of the four highest burden countries that we just talked about, have a huge proportion of the public that seeks treatment when they have a fever, not through public sector clinics, but rather through private pharmacies and drug shops and so forth. And the levels of testing and treatment in the private sector are not nearly what they should be. So that’s a challenge to focus on. The other thing we’re seeing is some changes in the vector, the mosquitoes that transmit malaria, there’s a vector that has emerged in Africa in recent years called Anopheles stephensi that is unlike most of its sisters, most of the other Anopheles mosquitoes, it’s actually an urban vector. And so, it breeds and bites in urban settings. It looks like pushing the boundaries of that biting window. Historically, Anopheles mosquitoes only bite at night. That’s why mosquito nets are so effective. If you sleep under a mosquito net, you’re not exposed to the risk of those infectious bites, but they’re now biting in cities where people stay out longer and may not use nets as much and are also biting earlier in the evening and later in the morning when people are less likely to be under nets.
How are mosquitos adapting to manmade malaria prevention methods?
Mark L. Goldberg [00:14:22] So the mosquito is adapting to our interventions.
Martin Edlund [00:14:27] It is indeed. We’re seeing mosquitoes adapt in a number of ways, and we talked about kind of where and when they bite, but also that they’re becoming resistant to some of the tools that we use like insecticide treated bed nets. So, of the 88 malaria endemic countries that provide data, 78 had detected resistance to at least one class of insecticide that’s commonly used in these nets. And so, this kind of miracle tool, long lasting, insecticide treated nets, that are responsible for the overwhelming majority of the lives saved and the historic progress that we’ve seen, they’re becoming less effective against some of the mosquitoes.
Why are insecticide-treated bed nets now less effective against malaria-carrying mosquitos?
Mark L. Goldberg [00:15:09] I feel like that’s a point worth emphasizing. You know, as long as I have been reporting on these issues, which stretches to the early 2000s, insecticide treated, long lasting bed nets were seen not as like a silver bullet, but as the most impactful and cost-effective way to prevent malaria deaths and illnesses. And you saw that reflected in the data since the early 2000s when these net distribution programs really got to scale, we saw this huge dramatic decline in cases and deaths. But you’re saying that now there is mounting evidence that these nets are indeed less effective? How concerning is this?
Martin Edlund [00:15:53] It’s quite concerning. The first thing to emphasize is that these tools still work. As the recent World Malaria Report shows, a million lives were saved just last year from the use of these tools. So, they’re still highly effective; they’re still arguably the single most cost-effective way to save lives on the planet. But we are seeing the spread of insecticide resistance in mosquitoes, and that means they’re not as effective as they once were. The upshot is we need to continue to innovate. We’re in a constant arms race with nature in deploying these tools, both in terms of insecticides and the drugs that we use to treat the parasite. The good news is that through investments and a lot of ingenuity, we have next generation nets. We have some new dual action nets that are highly effective. The challenge is that they’re slightly more expensive. And so, whereas we benefited over the last decade from volume growing, we went from about 17 million nets a year of being distributed to now more than 200 million distributed every year. And with that, the cost per net went from about $7 and then down to under $3. And well, now we’re seeing that price tick up. Whereas we’ve been able year over year to cover more and more people with the same funding for nets, now we’re going to have to prioritize or find new resources to maintain those high levels of coverage.
Is there a vaccine for malaria?
Mark L. Goldberg [00:17:20] Another key innovation in recent years was the advent of an impactful and effective vaccine against malaria that’s now recommended by the World Health Organization. What’s the status of that vaccine and its rollout, and where is it being rolled out?
Martin Edlund [00:17:41] Yes, so last year was really a landmark moment in the malaria campaign. For the first time, the World Health Organization in October of last year endorsed and recommended for wide use the first malaria vaccine. People are accustomed to the story with COVID of how quickly — Operation Warp Speed — how quickly vaccines were developed for COVID, but it’s taken about 30 years of research and effort to get to this first malaria vaccine. The challenge is malaria is a parasite and parasites are wily and harder to develop vaccines for. So, this was really a landmark moment to have the first W.H.O. endorsed vaccine for malaria and really vaccine for any parasite. The reality is it’s still not nearly as effective as we’d like. Over the long term, it’s only about 30, 35% effective, so it’s a great addition to the arsenal of current tools, but it’s not a silver bullet. It’s not something that’s going to replace the nets, testing treatment, seasonal malaria chemoprevention, the tools that we currently have. Nonetheless, a lot of enthusiasm, a lot of excitement for this. And so, three countries took on the initial distribution of this vaccine: Ghana, Kenya, and Malawi. They all saw good results from it, and so they’re expanding those programs now in those three countries, and a number of other countries are lining up to distribute the vaccine as well. The challenge is we have limited doses. GSK, who developed the vaccine, has only committed to about 15 million doses a year and people will require 3 to 4 doses over the course of a year. So, you’re really only talking about 5 million people protected. The reality is we need many times that. The true demand to protect the at-risk population would require more than 100 million doses annually. So, there’s a gap between the efficacy of the tool that we need; there’s also a gap in terms of the availability of the tool to really address the problem. Now, the exciting part is this has really sparked and spurred a whole range of innovations. There are subsequent vaccines which look to be even more effective that are rapidly moving through field trials. There’s a vaccine called R21, developed by Oxford’s Jenner Institute, working with the Serum Institute in India, that looks really compelling. We’re also seeing that BioNTech, one of the companies responsible for the COVID vaccines, is now trying to apply mRNA vaccine technologies, the same things that were used for COVID, for malaria, and actually trying to put those into clinical trials as quickly as they can.
How can we reach the World Health Organization goal of reducing malaria deaths by 90% by 2030?
Mark L. Goldberg [00:20:23] So broadly speaking, the trends over the last couple of years have shaken progress towards the W.H.O. goal of reducing deaths in cases by 90% by 2030, which is also embedded in the Sustainable Development Goals. Is accelerating progress towards that goal, at this point, simply a matter of scaling up the variety of interventions that you’ve previously discussed, like the seasonal prophylactics, the better bed nets, the more expanded use of the vaccines. Is it just a matter of scaling all of those up?
Martin Edlund [00:21:09] I think there are a couple of things. So maybe we can talk about risks and opportunities. On the risk side, we’ve got to get those next generation of tools out in the field and get them to the people who need them most. That requires more money; that requires investing in things like frontline distribution, community health workers who live and work day to day in the communities where malaria flourishes. Those are some of the opportunities that we have. We also know that malaria thrives on disruptions. We’ve seen, for instance, really compelling and devastating evidence of severe weather events being followed by severe health events. As many listening will be aware, Pakistan had really terrible flooding this year and there was so much talk about how devastating that was, kind of the physics of it. It washed out so much agriculture and people’s livelihoods. But what you see is a couple of weeks later, these severe health crises and malaria very much among them. There was a huge upsurge in malaria cases in parts of Pakistan. In one sample district, the Sindh Province, confirmed cases of malaria from August of this year reached about 70,000, compared to fewer than 20,000 the year before. So more than a tripling of malaria cases. And this is in a context of devastation. Roads being washed out, people not being able to access that routine care that they normally would. And so, climate is something we’ve got to think about increasingly with mosquito borne diseases and infectious diseases more broadly. But there are some exciting tools on the way, and maybe this points to one of the broader opportunities beyond just better nets and the next generation of treatments and so forth. There’s a pipeline that’s bursting with exciting new technologies. In fact, we think in the next five years that we’re going to see a suite of technologies that can equip the world to drive a big, not just elimination campaign in countries, but possibly eradication campaigns where in the space of a decade or so we could actually eliminate this disease once and for all.
What are monoclonal antibodies and how could they reduce malaria cases?
Mark L. Goldberg [00:23:27] What are some of those tech innovations that you’re referring to? Are there any, like, particularly promising ones you could tease for the audience?
Martin Edlund [00:23:35] I can, indeed, there are some very promising ones. So certainly, the vaccine candidates that we talked about are some of those. There are also monoclonal antibodies — people spoke about those a lot in the context of COVID — but when you think about a highly seasonal disease like malaria, that’s especially powerful. So, the National Institutes of Health and the US government and its partners have been developing some monoclonal antibody candidates that are in field trials now. They look to be more than 80% effective. So, contrast that with some of the lower efficacy levels that we talked about with vaccines, and they appear like they may last six months or more. So, when you actually look at the malaria endemic map and you look at those places that have intense seasonal transmission, those rainy seasons don’t last six months, so if you could go in, give people a single shot in the arm, protect them for an entire six months, you are essentially taking them out of circulation as potential victims and carriers of malaria for the entire rainy season. So those are two examples. A third one, and this one’s gotten a lot of coverage in the media, there are some really exciting technologies and approaches that can take mosquitoes from being the villain of the malaria story, the ones that transmit malaria to actually being part of the solution: genetic modification, and some other approaches that could prevent mosquitoes from transmitting malaria to people. And those are looking really exciting, both in the lab and in what they call these large trials. And so, we’re looking to see how those develop and ultimately whether they’re embraced by communities and can be taken up at a larger scale.
Mark L. Goldberg [00:25:20] So do you think by 2030, if we’ve reached those targets of reducing malaria instances and deaths by 90%, it will be due to technologies that don’t yet exist or at least exist at scale today?
Martin Edlund [00:25:38] I think, broadly speaking, there are three things we need to do to get back on track and even to accelerate progress to end this disease once and for all. As you know, my organization is called Malaria No More, so we’re looking at the end game. How do you ultimately eliminate this disease altogether? The first thing we can do is fill gaps with current tools. There are still large swaths of at-risk populations that don’t have access to these $3 nets, $1 treatments, and $0.35 rapid diagnostic tests. So, we have to fill those gaps to save lives now. The second thing we need to do is invest in frontline delivery, community health workers, scaling up highly effective tools in private sector clinics and pharmacies is a big part of how we reach the last mile and the people who ultimately need these interventions. And then on top of getting current tools out to the people who need them, we need to accelerate the technology pipeline. A child dies every minute from a mosquito bite, so we can’t wait 30 years for the next malaria vaccine candidate. We need to see more effective successor vaccines coming on much more quickly. We need to see the exciting progress around things like monoclonal antibodies moving from field trials into actual use very, very quickly. And then we need to be deliberate about it, but we need to explore the potential opportunities around genetically modified mosquitoes and some of the more novel techniques that could save lives now.
Mark L. Goldberg [00:27:10] Well, Martin, thank you so much for your time and for putting this most recent World Malaria Report in context. I appreciate it.
Martin Edlund [00:27:19] Thank you, Mark. Great to talk with you.
Mark L. Goldberg [00:27:28] Thank you for listening to Global Dispatches. Our show is produced by me, Mark Leon Goldberg, and edited and mixed by Levi Sharp.