The Road Ahead to Malaria Eradication

By Patrick Kachur on April 25, 2017

World Malaria Day arrives today with a theme that is equal parts ambition and aspiration—“End Malaria for Good.”

It’s catchy and encapsulates a universal goal. It also compels us to take unflinching stock to understand where we are in the fight against this beguiling foe. And more importantly, what needs to change to end a disease that still killed 429,000 people in 2015 and continues to exact an especially tragic toll on children under age 5 living in Africa.

The good news is, honest introspection allows for some optimism. We ought to celebrate enthusiastically the dazzling accomplishments of the past 15 years. At the same time there remain troublesome gaps in the science and practice of combatting malaria. In particular, better surveillance based on reporting confirmed malaria cases in real time can focus malaria resources where and when they will do the most good, serve as a tool for continuous evaluation and improvement, and provide a basis for early action when reversals and outbreaks appear.

Work to solve these problems—and others—is already underway. That is good news.

Here’s some more.

While malaria remains a global threat, the global effort has produced real achievement and tangible results in recent years. So much so that there is a real possibility, backed by science and experience, that malaria can be controlled and even eliminated in the next generation or two.

The gears are already turning.

We are already 16 months underway in the implementation of the World Health Organization’s (WHO) Global Technical Strategy (GTS) for Malaria, 2015–2030. GTS is an overarching strategy embraced by public health leaders for attacking malaria in all its complexity.

Importantly, the GTS defines a roadmap and metrics to guide and evaluate the progress of malaria control and elimination. It rests on three interdependent and important pillars:

  1. Ensuring universal access to malaria prevention, diagnosis, and treatment;
  2. Accelerating progress toward elimination; and
  3. Transforming surveillance into a core malaria intervention.

The first of these pillars continues to be a key focus each World Malaria Day. And for good reason.

Since 2001, malaria-affected countries and their global partners have reached hundreds of millions of people annually with proven tools for malaria prevention, diagnosis, and treatment. We know these tools work; billions of insecticide-treated nets, rapid diagnostic tests, and antimalarial drug treatments have contributed to saving 6.8 million lives, especially in areas most ravaged by malaria. An impressive feat for sure. However, progress has been uneven. These simple tools have yet to reach still millions more people at risk and they must be replaced year after year.

Ending malaria for good will require the continued commitment of partners to extend our reach even further, while at the same time identifying ways to target prevention, diagnosis, and treatment tools to where they’re most in need.

The second pillar is no less challenging. The GTS calls upon the global community to eliminate malaria in at least 35 countries by 2030. We’ve been down this road before. By the mid-1950s, malaria had been eliminated from dozens of countries and territories, including the United States (thanks in part to CDC’s early work, which incorporated federal efforts to help states eliminate malaria starting 75 years ago).

But as cases fell, complacency set in. Drug and insecticide resistance undermined the tools of the day. And the mid-20th century eradication effort ground to an unfortunate halt. And for at least 20 years after, not a single country was recognized for having eliminated malaria. Thankfully, the suspension of the global malaria eradication effort was temporary. Since 2007, seven countries have been certified by WHO as malaria-free, and another 12 countries reported zero cases in 2015. The current effort to “End Malaria for Good” is still gaining strength. WHO has developed A Framework for Malaria Elimination that asserts that to bend the curve towards reaching zero cases, we need to hasten access to the current interventions in high-burden countries and modernize the tool kit—developing new treatments when resistance threatens, fashioning innovative approaches to mosquito control, and pursuing progress toward an effective vaccine—even as increasing numbers of low-transmission countries embrace elimination.

While we can point to progress on the first two pillars, results related to the third are harder to appreciate. Better surveillance saves money and allows people and resources to be focused where they can do the most good, but gathering those data and developing a culture of using them to guide program decisions will require a massive pivot. That’s why my colleagues and I have spent hours pondering different strategies, approaches, and innovations. It’s an exercise rich in opportunities and promise since current technologies provide us new tools to make data collection, exchange, and interpretation more rapid and dynamic than ever before.

In countries on the cusp of eliminating malaria, such as South Africa, each illness case can trigger a local investigation to identify and contain transmission before it spreads further. In countries with a high number of malaria cases, such as Nigeria or the Democratic Republic of Congo, trying to investigate even a fraction of cases would quickly overwhelm local health officials. But the basic foundation to transform surveillance into an effective malaria intervention is starting to take shape, even in the highest-burden countries. Malaria rapid diagnostic tests (RDTs) have made it possible to distinguish malaria from other illnesses that similarly cause fever. In 2015 more than half of all malaria cases reported from high-burden African countries were diagnostically confirmed. This helps reduce the overuse and/or misuse of highly effective malaria treatment drugs and saves money.

But confirming diagnosis also does something else. It makes it possible to know with confidence when and where malaria cases are occurring. Malaria-endemic countries are just beginning to accommodate the potentially valuable information their diagnosis and treatment efforts generate. This type of Information was unreliable or unavailable even a decade ago, but the value of this new data is still under-recognized. Health information systems are adapting in ways that data can be shared more rapidly and accurately than before. But too few local health officials and malaria programs have the skills and experience to interpret trends and to target intervention tools where and when they are needed most. And the ability to recognize, confirm, and respond to potential reversals or outbreaks is even less well developed.

So on World Malaria Day, as we celebrate the unquestioned progress made over the past 15 years, there’s a need to maintain the recent commitment and momentum as well as further our progress and focus our finest thinking to gather and use data we are already generating—to guide decisions and measure progress. Without a doubt, prevention, diagnosis, and treatment investments will continue to have the most tangible and inspiring impact on the considerable burden of malaria morbidity and mortality. But World Malaria Day is also an important chance to apply clear-eyed, even skeptical, analysis to what must take place to end malaria for good.