Holding the line against malaria in 2021 despite ongoing challenges

The World Health Organization’s World Malaria Report (WMR) 2022 reveals that fewer lives were lost to malaria in 2021, ~619,000 compared to 625,000 in 2020; however, case numbers rose by 2 million from 245 million in 2020 to 247 million. Regrettably, a child continues to die from malaria every minute of the day.

WHO described this generally stable trend as national malaria control programmes ‘holding the line’ against the disease despite COVID-related disruptions to malaria services and other biological threats such as drug resistance.

A perfect storm of threats

Efforts to curb malaria face a perfect storm of threats, particularly in the Africa Region, which carries the heaviest burden of the disease. The COVID-19 pandemic is reported to have led to 63,000 more malaria deaths and 13 million additional cases owing to disruptions in the provision of malaria care. This is further compounded by humanitarian crises due to war and climate change, e.g., famine and flooding. Health system challenges and rising biological threats are also undermining key malaria control tools.

A major concern is that drug resistance could undermine the utility of artemisinin-based combination therapies (ACTs), the gold-standard treatment for malaria. Partial resistance to artemisinin has been confirmed in the Greater Mekong Subregion and in three African countries: Eritrea, Rwanda and Uganda. To date, ACTs remain largely effective, yet given the reliance of health systems on these vital medicines, widespread treatment failure would have grave consequences.

These threats are intensified by a widening funding gap. In 2021, USD 3.5 billion was invested globally in malaria control and elimination – i.e., less than half the target of USD 7.3 billion. At the same time, the Global Fund to Fight AIDS, Tuberculosis and Malaria raised USD 15.7 billion against the targeted USD 18 billion.

Getting back on track and tackling resistance with new tools

WHO proposes two approaches to get the malaria fight back on track. First, building endemic country resilience and second, the research and development of new tools. The resilience of endemic countries came to the fore in response to the pandemic, yet at the same time, fragilities in health systems were highlighted. WHO has provided several new and updated inter-related strategies to support a coordinated approach to malaria control, for example, their WHO initiative to stop the spread of Anopheles stephensi in Africa and Strategy to respond to antimalarial drug resistance in Africa.

The resistance strategy, aimed at minimizing the threat and impact of antimalarial drug resistance on the continent, calls for the use of preventive measures to reduce transmission of resistant parasites, the deployment of new tools to delay the development and spread of resistance, as well as the development of new tools effective against resistant strains.

MMV’s work is particularly important here. This year, seasonal malaria chemoprevention (SMC), an MMV-supported intervention, protected 46 million children from malaria, up from 2.5 million in 2014, the second year of implementation. Furthermore, SMC also proved more cost-effective and efficacious than current malaria prevention interventions, such as bed nets, indoor spraying with insecticides and the RTS,S malaria vaccine. At USD4 per child per year, it is nine times cheaper than a full course of the vaccine and over twice as efficacious.

Meanwhile, in November, WHO’s new malaria treatment guidelines strongly recommended MMV’s co-developed ACT pyronaridine-artesunate, providing a new tool to help further delay the development of drug resistance. In the same month, together with Novartis, MMV announced the decision to move to Phase 3 for a novel non-artemisinin combination therapy, ganaplacide/lumefantrine. If all goes well, the therapy will provide an alternative to ACTs when resistance takes hold and ensure children can continue to be treated for this deadly disease.

Focusing on children and pregnant woman

As the WMR notes, children and pregnant women are at elevated risk of malaria and its consequences. Yet, at the same time, their needs have not always been prioritized. MMV is working to change that. Coverage of intermittent preventive treatment in pregnancy (IPTp) rose slightly in 2021 with 35% of eligible women receiving the recommended three doses as compared to 32% in 2020. Through its Malaria in Mothers and Babies (MiMBa) initiative, MMV is working with key players to support increased coverage of this important intervention and to accelerate research into antimalarials for women who are pregnant, breastfeeding or of reproductive potential.

“We are at a pivotal moment in the fight against malaria,” said Dr David Reddy, CEO of MMV. “Globally, an estimated 2 billion cases and 11.7 million deaths were averted between 2000 and 2021 due to the concerted efforts of the entire malaria community. This was immense progress. Yet since 2017, this progress has been stagnating. And then the pandemic hit, and matters got worse.

“Today, we are facing a perfect storm of threats against the backdrop of a widening funding gap. Now is the time for the entire malaria community, including funding partners, to ramp up global efforts or we risk further slippage in the gains made. We cannot allow the loss of more young lives to malaria – at MMV we are committed to bringing forward tools that will pave the way for a malaria-free future.”