On 29 October, an article written by MIM Secretariat Francis Ntoumi and AMANET Managing Trustee Wen Kilama was published in The Lancet. This article sets the stage for the MIM Conference by discussing the progress that has been made in the global fight against malaria, the threat posed by growing insecticide and drug resistance and the importance of current malaria R&D efforts.
Lancet: Malaria: a research agenda for the eradication era
By Francine Ntoumi and Wen Kilama
The world’s largest meeting on malaria, the 5th Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference, convenes in Nairobi, Kenya, on Nov 1—6. Since the last MIM meeting in 2005, the malaria landscape has transformed dramatically. Scientific progress and support from the highest levels of government galvanised the field, and the global community has begun to coalesce around the most ambitious goal possible—eradication.
Today, malaria-control efforts, particularly in Africa, have extraordinary visibility and unprecedented financial support from governments and philanthropic foundations. In Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), approved grants for malaria exceed those for AIDS and tuberculosis combined. African governments are playing a larger role in efforts to eliminate malaria deaths, and creative partnerships with political and celebrity champions have accelerated the distribution of millions of insecticide-treated bednets. In all, increased control efforts, including uptake of artemisinin-based combination therapies (ACTs), have led to a 50% decline in malaria cases and deaths in 29 countries since 2000, including in seven countries in Africa.
Behind these successes, however, lies a worrying reality: the spread of drug and insecticide resistance threatens to unravel the progress. Malaria strains resistant to the cheapest and most commonly used drugs already exist in almost every endemic country. Now, irrational use and continued over-reliance on artemisinin monotherapies are undermining the gold standard for malaria treatment, ACTs. Last year, a study showed significantly longer parasite-clearance times in patients taking ACTs along the Thai—Cambodian border. With no new classes of drugs in late-stage development, resistance to ACTs could render ineffective many of the endoperoxide drug candidates being developed as synthetic alternatives to artemisinin.
Insecticide resistance is also spreading. Long-lasting insecticidal bednets and indoor residual spraying have saved millions of lives, but we are victims of our success. Expanding access to insecticides, combined with agricultural spraying practices, is putting evolutionary pressure on mosquitoes to develop resistance. In east Africa and other areas, two species of mosquito have already been found to be resistant to commonly used insecticides, including permethrin and DDT. Worse, there are no new classes of insecticides in late-stage development. The Global Malaria Eradication Programme of the 1950s and 1960s failed in part because of resistance. We must learn from the past, and focus on research that accelerates development of new tools and supports effective use of existing ones.
Evidence-based mechanisms are needed to improve access to effective treatments and displace monotherapies. Today, only 3% of children under the age of 5 years receive ACTs, partly because 40—60% of patients are treated in the private sector where ACTs remain prohibitively expensive. The Affordable Medicines Facility for Malaria (AMFm) is an innovative approach to reduce ACT costs. To support the AMFm and other efforts, the ACTwatch project is collecting data on market penetration for ACTs and building recommendations on how to increase access to and affordability of ACTs.
At the same time, operational research is crucial to determine which methods and policies can improve availability of existing interventions. Recent studies show that trained community volunteers can deliver antimalarial treatments successfully. Lessons learned today will speed access to new tools as they become available.
We also need better diagnostics. The lack of accurate diagnostic tools leads to overprescribing of antimalarials by as much as 90% in some resource-poor settings, potentially contributing to resistance. An ongoing study of various rapid diagnostic tests is shedding light on their effectiveness in different settings, but more research is needed.
New or improved tools remain our best hope for eradication. The world may be 5 years away from a partly effective malaria vaccine with the potential to save hundreds of thousands of lives. The most advanced vaccine candidate, RTS,S, is now in phase 3 clinical trials in seven African countries. It is time to start discussing financing and delivery even as we invest in next-generation vaccine candidates, including transmission-blocking and whole-organism vaccines.
At the founding of MIM just over a decade ago, essential malaria research in Africa was minimal. Malaria research initiatives, many of which are led by Africans, are now working with MIM and strengthening Africa’s ability to spearhead the development of new tools and approaches for malaria control. But while African researchers celebrate recent progress, we remain all too aware of the disease’s resilience and continued toll. Substantial political and financial support is needed, along with a critical mass of scientists working on malaria in sub-Saharan Africa, to maintain and implement an effective malaria research agenda.
How many lives will be saved by what we learn at this conference? With 2200 malaria deaths in Africa every day, we cannot afford to let up on our crucial mission.
AMANET has received funding from the European Commission, EDCTP, DANIDA, and the Dutch Government. FN is a member of the Special Programme for Research & Training in Tropical Diseases (TDR) Task Force on Malaria Research Capability Strengthening in Africa, and was scientific officer for EDCTP.
To access the article online, please visit:
http://www.lancet.com/journals/lancet/article/PIIS0140-6736(09)61884-5/fulltext?_eventId=login
