World Malaria Day

On April the 25th, we celebrate World Malaria Day, an opportunity to celebrate humanities’ advances in combating one of the deadliest diseases in the world, and look forward to what work needs to be done. This year the World Health Organisation has chosen the theme “Time to Deliver Zero Malaria: Invest, Innovate, Implement”. Here, we explore what this means and how we can achieve zero malaria. Malaria, once a globe-spanning disease endemic to countries as far flung as the US, UK, China and Russia has been subject to continuous research and eradication efforts. It has been almost entirely eliminated from Europe, North America and North Asia, with the parasite now residing largely in sub-Saharan Africa (12, 13). With so much progress made, it’s up to us to finish the job.

Understanding Malaria and its Impacts

Malaria is a life-threatening disease, causing flu-like symptoms of high temperature, yellowing skin and eyes, and difficulty breathing (14). It is transmitted through bites from female Anopheles mosquitoes that take blood from infected humans and deposit the infected blood into others, spreading the malaria parasite. The World Health Organization (WHO) estimates there were 229 million cases of malaria in 2019, resulting in 409,000 deaths (1). And malaria not only destroys lives, but also has incredibly detrimental socio-economic impacts. Endemic malaria causes countries to grow 1.3% less per person per year than would otherwise be the case, alongside being a significant burden on national healthcare spending (15). So ending malaria will not only save lives, but also make the lives we already lead more prosperous. Additionally, malaria disproportionately affects children under five years of age, who make up 67% of its victims (2). Pregnant women also suffer high mortality rates, being 3 times more likely to suffer debilitatingly from the disease compared to non-pregnant women (16).

Progress In Malaria Prevention and Control

Malaria Control Strategies

A key way to achieve zero malaria is stopping the spread, or ‘Vector Control’. Vector control reduces the number of mosquitos (‘vectors’) the parasite is carried by. This is done in two ways; using Insecticide-Treated Mosquito Nets and Indoor Residual Sprays. Insecticide-Treated Mosquito Nets (ITNs) are one of the most effective ways to stop malaria. Covering a bed with one creates a barrier that kills the mosquitos with insecticide, reducing bites and preventing infection. The WHO estimates ITN use has averted 68% of malaria cases in sub-Saharan Africa between 2000 and 2015 (5). Conversely, Indoor Residual Sprays spread insecticide on the walls and ceilings of houses to kill the mosquitoes directly, reducing their numbers and preventing bites. By using Residual Sprays alongside ITNs, a range of insecticides can be presented, increasing the chance that infectious mosquitos will die and not be able to spread the parasite. Finally, antimalarial drugs can reduce the spread by presenting fewer infected targets for the mosquitos to take blood from, meaning fewer infected mosquitos and fewer overall infections (17).

Innovations in Malaria Research

Innovation is another crucial component of achieving zero malaria. New tools and strategies to combat the disease reduce the costs of fighting the disease and enhance existing methods. For example, one brilliant innovation has been the development of a malaria vaccine. In 2021, the WHO recommended use of the first ever malaria vaccine, after two years of pilot studies. Evidence shows that this vaccine delivers a 30% reduction in deadly severe malaria in children aged 5 and under when combined with other reduction methods such as the use of ITNs and IRS (18). New vector control techniques are also being developed, such as the use of drones to spray anti-mosquito ‘films’ over rice fields and pools of water. This reduces the number of mosquito larvae that survive to adulthood, reducing the possibility of transmission (8,9).

Malaria Eradication Success Stories

One fantastic example of the ongoing efforts to destroy malaria is in El Salvador, that the WHO was able to declare ‘malaria-free’ in 2021 (19). Through a gargantuan human effort to monitor the spread of the parasite and administer antimalarial drugs, El Salvador recorded its final malaria death in 1984, with attendant cases dropping significantly throughout the 90s and 2000s.

Challenges to Malaria Eradication

What challenges remain for reaching zero malaria? There are two significant issues for global efforts: drug resistance and funding. The WHO has found that certain antimalarial drugs are becoming less effective as the malaria parasite develops resistances to their effects. In particular, resistance to the antimalarial drug ‘artemisinin’ has become pronounced (20). As these drugs become less effective, those suffering with malaria will have fewer treatment options, alongside becoming additional vectors for mosquitoes to pick up the disease from. Similarly, the mosquitoes’ own resistances to insecticides causes concern. Given that current control of the malaria parasite relies on the efficacy of these insecticides to control mosquito populations, it is crucial that these resistances are monitored and responded to effectively. Distressingly, in the 38 countries that reported resistance data, 27 reported high-intensity resistance over 293 sites, and moderate to high intensity was reported in 34 countries over 406 sites (21). Finally, funding for the WHO’s malaria response has sadly fallen short of the necessary targets for several years. While global malaria funding hit an all-time high in 2020 of $3.3 billion, it is still short of the $6.8 billion required to stay on track for the WHO’s Global Technical Strategy for malaria, which aims to eliminate malaria by 2030 (22). This shortfall has increased over the years, given previous shortfalls in funding (23).

International Organisations Fighting Malaria

It’s impossible to talk about World Malaria Day without talking about the WHO. Evolving from the Global Malaria Eradication Programme in 1955, the WHO coordinates global efforts to control and eliminate malaria through the Global Malaria Programme. The GMP disseminates global policy and advice on fighting malaria and aids nations in producing malaria strategies and surveillance systems; producing an annual report on malaria trends and elimination efforts, an essential resource for healthcare professionals across the globe. Outside the WHO, there is also the Roll Back Malaria Partnership (RBMP) and the Global Fund to Fight HIV & Aids, Tuberculosis and Malaria (The Global Fund). The RBMP works with nations and partners to supply funding, launched in 1998 by the joint efforts of the WHO, UNICEF, United Nations Development Programme and World Bank. It provides governments with strategy advice and products to the fight against malaria, Meanwhile, the Global Fund finances initiatives and projects that fight diseases and illness around the world - providing 63% of all international financing for malaria programmes.

The Road Ahead: The Future of Malaria Eradication

As we have seen, new technologies and research into the malaria parasite hold a lot of promise for its eventual eradication, from the groundbreaking development of a vaccine to the brilliant use of new drone technologies in reducing mosquito numbers in malaria-endemic areas. But technology isn’t the only way for us to eradicate malaria. The Malaria Consortium provides evidence that community-based primary healthcare is also essential by linking communities to the wider formal healthcare system. By training local volunteers in malaria prevention techniques and services, the skills required to combat malaria can be spread over a much larger range than formal services can achieve, alongside providing community contacts to assist in the dissemination of malaria treatments when needed (24). Malaria control interventions are most effective when they are tailored to the needs and preferences of the communities they serve (10). Engaging communities in the design and implementation of interventions can improve their acceptability and effectiveness, building crucial trust between communities and healthcare providers. Monitoring and evaluation are also essential for effective implementation (11). Malaria control programs must be regularly monitored and evaluated to assess their impact and identify areas for improvement. This includes monitoring the coverage and effectiveness of interventions, as well as tracking changes in malaria incidence and mortality. Regular monitoring and evaluation can help to identify areas where interventions need to be strengthened and can help to ensure that malaria control efforts are achieving their intended goals.

So… How Can You Help?

Massive gains have been made in the global fight against malaria, from the development of a vaccine to the development of drone and netting technologies that will further reduce the vectors that the parasite can spread through. These are massive achievements, highlighting the importance of World Malaria Day. But there is more work to do. From reducing the funding shortfall to creating new insecticides that mosquitoes will not be resistant to, eradicating malaria will take a lot more collective effort. If our discussion has given you any ideas on how you can contribute to the eradication of malaria, follow that spark and find out how you can get involved! The top charities working to end malaria today are the Malaria Consortium, and the Against Malaria Foundation, both of whom have received ‘exceptionally strong’ evidence of impact ratings. Find their Just Giving page. Alternatively, the WHO has a Global Internship Programme for students and recent graduates in medicine or a related field.

References

Primary References

1. World malaria report 2020: 20 years of global progress and challenges. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO pg. 19
2. World malaria report 2020: 20 years of global progress and challenges. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO pg. 18
3. World malaria report 2021. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. pg. 56
4. World Health Organisation 2018. Geneva: World Health Organization; 2015. pg. 26
5. Bhatt, S., Weiss, D., Cameron, E. et al. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature 526, 207–211 (2015). https://doi.org/10.1038/nature15535
6. World Health Organisation 2023, WHO publishes recommendations on two new types of insecticide-treated nets [https://www.who.int/news/item/14-03-2023-who-publishes-recommendations-on-two-new-types-of-insecticide-treated-nets#:~:text=Over%20the%20last%202%20decades,%2Dto%2Dhigh%20transmission%20areas.]
7. Mouatcho JC, Goldring JPD. Malaria rapid diagnostic tests: challenges and prospects. J Med Microbiol. 2013 Oct;62(Pt 10):1491-1505. doi: 10.1099/jmm.0.052506-0. PMID: 24048274.
8. Waita, E. (2019) Researchers Use Drones to Pilot a New Tool to Fight Malaria, online [https://www.reuters.com/article/us-tanzania-malaria-idUSKBN1XF1HW]
9. Morgan, D. (2022) Malaria: Aberystwyth University drone system used in Zanzibar, online [https://www.bbc.co.uk/news/uk-wales-60509702]
10. Awasthi KR, Jancey J, Clements ACA, et alCommunity engagement approaches for malaria prevention, control and elimination: a scoping review protocolBMJ Open 2021;11:e049812. doi: 10.1136/bmjopen-2021-049812
11. Rajvanshi H, Nisar S, Bharti PK, Jayswar H, Mishra AK, Sharma RK, Saha KB, Shukla MM, Das A, Kaur H, Wattal SL, Lal AA. Significance of training, monitoring and assessment of malaria workers in achieving malaria elimination goal of Malaria Elimination Demonstration Project. Malar J. 2021 Jan 7;20(1):27. doi: 10.1186/s12936-020-03534-9. PMID: 33413408; PMCID: PMC7789890.
12. World malaria report 2020: 20 years of global progress and challenges. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO pg. 22
13. Simon I Hay, Carlos A Guerra, Andrew J Tatem, Abdisalan M Noor, Robert W Snow, The global distribution and population at risk of malaria: past, present, and future, The Lancet Infectious Diseases, Volume 4, Issue 6, 2004, Pages 327-336, ISSN 1473-3099, https://doi.org/10.1016/S1473-3099(04)01043-6
14. NHS Malaria, online [https://www.nhs.uk/conditions/malaria/]
15. Andrade, M.V., Noronha, K., Diniz, B.P.C. et al. The economic burden of malaria: a systematic review. Malar J 21, 283 (2022). https://doi.org/10.1186/s12936-022-04303-6
16. Schantz-Dunn J, Nour NM. Malaria and pregnancy: a global health perspective. Rev Obstet Gynecol. 2009 Summer;2(3):186-92. PMID: 19826576; PMCID: PMC2760896.
17. World Health Organisation Treating Malaria, online [https://www.who.int/activities/treating-malaria]
18. World Health Organisation (October 2021) WHO Recommends Groundbreaking Malaria Vaccine for Children at Risk, online [https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk]
19. Balakrishnan, V. S. (2021) El Salvador’s Malaria Elimination Success Story, The Lancet Microbe, Volume 2, Issue 5
20. World malaria report 2021. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. pg. 91
21. World malaria report 2021. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. pg. 98
22. World Health Organisation (2021) Global Technical Strategy for Malaria 2016 - 2030, 2021 Update, online [https://www.who.int/publications/i/item/9789240031357]
23. World malaria report 2021. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. pg. 98
24. Malaria Consortium (2017) Community-based Primary Healthcare: the key to unlocking health for all, online [https://www.malariaconsortium.org/news-centre/community-based-primary-healthcare-the-key-to-unlocking-health-for-all.htm]

Secondary References

1. World Health Organization. World malaria report 2021: 20 years of global progress and challenges. Geneva: World Health Organization; 2021. Available from: https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2021
2. World Health Organization. High burden to high impact: a targeted malaria response. Geneva: World Health Organization; 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/275868/WHO-CDS-GMP-2018.25-eng.pdf
3. World Health Organization. Global technical strategy for malaria 2016-2030. Geneva: World Health Organization; 2015. Available from: https://www.who.int/publications/i/item/9789241564991.
4. World Health Organization. Malaria vaccine: WHO position paper – January 2016. Weekly Epidemiological Record. 2016; 91:33–52.
5. World Health Organization. Achieving and maintaining universal coverage with long-lasting insecticidal nets for malaria control. Geneva: World Health Organization; 2017. Available from: http://apps.who.int/iris/bitstream/handle/10665/259478/WHO-HTM-GMP-2017.20-eng.pdf?ua=1?sequence=1
6. World Health Organization. Indoor residual spraying: use of indoor residual spraying for scaling up global malaria control and elimination. Geneva: World Health Organization; 2006. Available from: https://apps.who.int/iris/bitstream/handle/10665/69386/WHO_HTM_MAL_2006.1112_eng.pdf?sequence=1&isAllowed=y
7. World Health Organization. Guidelines for the treatment of malaria. 3rd ed. Geneva: World Health Organization; 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/162441/9789241549127_eng.pdf?sequence=1&isAllowed=y
8. World Health Organization. Community engagement for malaria control. Geneva: World Health Organization; 2019. Available from: https://www.who.int/docs/default-source/documents/global-technical-strategy-for-malaria-2016-2030.pdf
9. World Health Organization. Malaria elimination: a field manual for low and moderate endemic countries. Geneva: World Health Organization; 2007. Available from: https://apps.who.int/iris/bitstream/handle/10665/254761/9789241511988-eng.pdf
10. World Health Organization. Monitoring and evaluation for malaria control and elimination: a technical brief. Geneva: World Health Organization; 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/272284/9789241565578-eng.pdf
11. Roll Back Malaria Partnership. The global technical strategy for malaria 2016-2030. Available from: https://www.who.int/docs/default-source/documents/global-technical-strategy-for-malaria-2016-2030.pdf
12. Malaria No More. Malaria facts. Available from: https://malarianomore.org.uk/world-malaria-report-2018-progress-and-peril
13. Centers for Disease Control and Prevention. Malaria. Available from: https://www.cdc.gov/malaria/index.html.
14. United Nations. Sustainable Development Goals. Available from: https://www.un.org/sustainabledevelopment/sustainable-development-goals/.
15. Roll Back Malaria Partnership. End Malaria Council. Available from: https://endmalaria.org/
16. Awasthi KR, Jancey J, Clements ACA, et alCommunity engagement approaches for malaria prevention, control and elimination: a scoping review protocolBMJ Open 2021;11:e049812. doi: 10.1136/bmjopen-2021-049812
17. Mouatcho JC, Goldring JPD. Malaria rapid diagnostic tests: challenges and prospects. J Med Microbiol. 2013 Oct;62(Pt 10):1491-1505. doi: 10.1099/jmm.0.052506-0. PMID: 24048274.
18. Waita, E. (2019) Researchers Use Drones to Pilot a New Tool to Fight Malaria, online [https://www.reuters.com/article/us-tanzania-malaria-idUSKBN1XF1HW]
19. Morgan, D. (2022) Malaria: Aberystwyth University drone system used in Zanzibar, online [https://www.bbc.co.uk/news/uk-wales-60509702]
20. Rajvanshi H, Nisar S, Bharti PK, Jayswar H, Mishra AK, Sharma RK, Saha KB, Shukla MM, Das A, Kaur H, Wattal SL, Lal AA. Significance of training, monitoring and assessment of malaria workers in achieving malaria elimination goal of Malaria Elimination Demonstration Project. Malar J. 2021 Jan 7;20(1):27. doi: 10.1186/s12936-020-03534-9. PMID: 33413408; PMCID: PMC7789890.