The Big Takeaway from the WHO’s Annual Malaria Report: A Change of Mindset is Desperately Needed.
Grey Frandsen, CEO of Oxitec’s response to the WHO World Malaria Report 2022
The annual report celebrates progress on certain fronts in the war against malaria. But it also highlights that some of the most significant challenges are just beginning to emerge, and that the international community is not yet prepared.
I’m always eager to get my hands on the World Health Organization’s annual report on malaria (key global messaging here), as it highlights the macro-level and country-specific trends that help us understand how we’re doing in our pursuit of malaria elimination. The WHO team that assembles the report does an outstanding job both in the quality of the compilation of extensive datasets and its analysis, and the distillation of the overarching narrative and key messages.
This year’s report is especially important, as it covers a period within which COVID-19 saw its devastating peak and decline in certain malaria-endemic countries. We’d hope to start seeing meaningful data relating to the impact that COVID has had on malaria control efforts, how far behind we may have fallen because of re-allocated health resources or general burden on public health systems, and what we need to do to catch up.
As one might imagine, the malaria fight is now more important than ever.
The Good News
Thankfully, there are a few bright spots in the report this year.
Most importantly, lives were saved. Front-line health and vector control workers around the world battled through lockdowns, diminished resources, waning political will, failing tools, and a range of other obstacles to deliver life-saving services to communities. Their critical work helped translate to important geographic gains, too - in 2021, 84 countries were considered malaria-endemic countries, which is a sizable drop from 108 in 2000.
Another bright spot - use of insecticide-treated bed nets (ITNs) in sub-Saharan Africa also improved significantly, with the percentage of the people sleeping under an ITN increasing from 2% to 47%, and children aged under 5 sleeping under ITNs increasing from 3% to 53%. These simple, (relatively) inexpensive interventions have outsized impact.
This is positive news and further evidence that malaria control investments globally can translate into lives saved.
The Bad News
Unfortunately, despite gains in some areas, the progress against malaria globally is now backsliding and there are major headwinds to further progress. In 2020, 241 million malaria cases and 627,000 malaria-related deaths represented increases over 2019. Put another way by the report’s author, we missed the 2020 targets of malaria case incidence and malaria-related mortality by 40% and 42% respectively.
There are a number of challenges that have led to this lack of progress, and COVID is a big part of it. But malaria control challenges were expanding before COVID. For example, parasite resistance to life-saving malaria treatment drugs is rising, and as malaria parasites evolve, the effectiveness of the ever-important and low-cost rapid diagnostic tests (RDTs) used to quickly detect malaria in patients is threatened. The WHO report provides important details on these items.
But the report also highlights two confounding challenges that together may form one of the greatest threats to malaria elimination efforts in generations: the continued rise of insecticide resistance amongst malaria vectors and the rapid spread of a new urban malaria vector, Anopheles stephensi.
In other words, traditional tools aren’t working well enough, and a new vector is on the rise. This is a troubling combination.
Insecticide resistance is not new, but the report clearly demonstrates how the problem is getting worse.
Chemical pesticides have played an important role over the decades and will continue to do so, but data provided between 2010 and 2020 shows that 78 of the 88 malaria-endemic countries have detected mosquito resistance to at least one insecticide class, and an astonishing 19 of the 88 countries have detected a level of resistance to all four commonly used chemical classes: pyrethroids, organochlorines, carbamates and organophosphates. New active ingredients are expensive to develop, require long development timelines, see resistance generated quickly, and are not without trade-offs to local ecosystems.
In a recent visit to northeastern Uganda, I met with local political leaders who shared the pain of using precious limited resources on chemical pesticide sprays in villages, only to know their effectiveness is limited. In Tanzania, Kenya, Djibouti and other countries I've visited recently, the message was the same.
Anopheles stephensi is posing a new and significant threat to the African continent and beyond.
As a new invasive city-dwelling malaria vector in Africa, An. stephensi is now causing urban malaria outbreaks and is spreading rapidly throughout African cities across the continent (documented from Djibouti to Nigeria, and beyond). Urban malaria transmission is a new front in the fight against malaria, and as of now, the malaria control community is largely under-equipped to manage it. An. stephensi is a daytime biter, rendering the night-time benefits of ITN as largely ineffectual. In African cities, spraying insecticides in peoples’ dwellings is more impractical than it is in rural settings, and an endless supply of breeding sites means that managing larval breeding habitats is near-impossible.
Public health institutions are also not yet ready to handle this new disease burden. Yet to be exposed to malaria outbreaks at the heart of cities, and faced with growing urban populations and other public health challenges, health infrastructure in many major African cities is not yet up to the challenge.
Addressing Changing Threats Requires Changing Mindsets
So, what to do? I'm convinced that continuing to do what we've been doing won't yield better results. And small, marginal improvements around the edges of how we control malaria today won't deliver the big gains we need to eliminate this disease in the coming years.
In my view, we need to carry out a complete overhaul of the tools and systems used to combat these challenges and to do so, a radical change in mindset is required.
And yes, I’m biased. I lead Oxitec’s team of world-class technology developers and mosquito control, public health and public engagement experts, which is developing a new self-limiting An. stephensi: a chemical-free, highly-effective, safe and environmentally sustainable solution for this invasive threat perfectly suited to control the vector in complex urban settings. It may also have a resistance dilution effect, helping to reverse the diminishing performance of traditional tools (you can read more about it here). We’re working around the clock to complete this new groundbreaking technology and get it into the hands of public health officials and communities who are eager to deploy it.
But our new technology alone won’t be sufficient. There are a number of areas that need such an overhaul or re-think. Here are a few areas that I believe are critical components to reshaping our fight against malaria globally.
Stronger early warning and surveillance systems are overdue. New investments and new innovations in the monitoring and surveillance space are needed, as it’s hard to fight an enemy like An. stephensi when we don’t know where it is. Some outstanding work is being done here, with local mosquito control experts in a range of countries leading new approaches, carrying out careful trapping and analysis and using new systems for information sharing. But capacity is uneven from country to country and district to district, and monitoring and surveillance technology is still largely what our colleagues were using decades ago. I’m following a handful of companies doing outstanding work in this space – ranging from using biotechnology to detect mosquitoes or parasites to using AI and new smart traps to create a better view of the vector control landscape in near-real time. New innovations in this space can't come soon enough, particularly as we face a new urban malaria vector in new geographies.
A new generation of vector control technologies is needed. Traditional tools have been able to deliver life-saving benefits over the last few decades, but we’re now backsliding, and we can’t expect decades-old technologies to deliver new results. To that end, we’re proud to be developing a new self-limiting An. stephensi that will be perfectly suited to control the vector in complex urban environments, as mentioned above. Other technologies are in the works, too, ranging from simple tools like eve tubes to new toxic sugar baits, in addition to re-thinking the traditional chemical pesticide approach. I’m impressed with the International Vector Control Consortium’s (IVCC) Product Development Partnership (PDP) model and their work to use collaboration, advocacy and market shaping to get new vector control technologies to market.
Faster innovation-to-market processes will help unlock the value of those new technologies. We saw how quickly COVID vaccines were developed and approved. No such urgency has been placed on any technology relating to malaria that I’m aware of, which is heartbreaking. Thankfully, I’m not alone in the belief that we need a major overhaul for how the malaria community invests in, assesses and endorses new, proven technologies for scale-up. I’m thankful for the work being done by a number of other organizations to help streamline how vector control technologies get to communities that need them the most. Still, we have a lot of work to do. Faster, clearer paths for innovations to get to market will translate into more investment in innovations, which in turn results in more viable solutions. Just as our enemy is adapting, so too must our technologies and systems for advancing them to deployment. We need less bureaucracy and more urgency, and I'm hopeful that improvements in the WHO system for evaluating new technologies will help this.
Modernized regulatory frameworks are a prerequisite for realizing the benefit of new technologies. A new generation of safe technologies like ours requires updated thinking on how to regulate vector control technologies efficiently. In malaria-endemic countries, regulatory systems are diverse. Some national frameworks are agile and are adapting to new categories of technologies while remaining focused on ensuring that any new mosquito control solution is safe for people and the environment. But some governments are just now starting to increase their capacity and expertise for assessing new technologies. Good work is being done on this front, thankfully, and it’s clear that there is broad consensus about the need for harmonizing regulatory frameworks. There is a growing community of experts and regulatory specialists focused on biotechnology, for example, and as companies like ours continue to demonstrate efficacy, safety and sustainability from one country to another, this will become less of a hurdle to deploying innovations and more so an important part of assessing and accelerating new, safe solutions to the market for impact.
New malaria challenges will require a new level of political will. Without renewed or continued political leadership by African leaders, donor countries and international organizations, it’s hard to envision us reversing the trend lines. Thankfully, good work is being done on this front. Among other groups, I’m a fan of Malaria No More, Malaria No More UK, and the African Leaders Malaria Alliance (ALMA - check out their excellent scorecard), each of which is working to mobilize political and social will for resources and action to fight malaria. These organizations have done wonders for elevating malaria on the political agenda of key donor nations and international organizations, and have organized effective advocacy campaigns that work to keep malaria in the mainstream consciousness. But clearly, given the data in this report, more needs to be done to mobilize financial resources and political will to expand the war on malaria, not just keep the status quo. An excellent opportunity takes place next week, as the heads of state from most African countries will be in Washington DC for the U.S.-Africa Leaders Summit and where big issues will be on the agenda. It is imperative that expanded funding and new political commitments to control malaria is on the agenda - and high on it. Millions of lives depend on it.
Plenty more needs doing, of course, and it's never as easy as one blog post might suggest, but as we continue to unpack the lessons that this annual report provides, I think one message is crystal clear – what we’ve been doing has been necessary to save millions of lives to date, but it isn’t sufficient for the lives we must save going forward, and thus a transition in mindset is urgently needed.
Thankfully, in each of these areas, and beyond, there is an incredible community of committed public servants, innovators, experts, advocates, champions, and entrepreneurs who are devoting their lives to solving this global burden. I'm continually inspired by their commitment and ingenuity, and I have no doubt that thanks to them we'll soon be back on track to eliminate this disease in our lifetime.