Can malaria finally be eradicated?

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Specifically for the New York Times Infobae.

(Science Times: Global Health)

Miriam Abdullah spent her entire childhood in and out of hospitals, her thin body racked with fever and plagued by malaria. She got sick so often that her constant treatments exhausted her parents, who also cared for her many siblings, both financially and emotionally.

“There was a time when even my mother gave up,” recalls Abdullah, now 35.

In Nyalenda, the poor community in Kisumu, Kenya, where Abdullah lives, malaria is endemic and pervasive. Some of his friends developed meningitis after infection; one of them died. “Malaria has really plagued us as a country,” he said.

There are millions of horror stories like Abdullah’s that are passed down from generation to generation. But now a change is imminent: malaria is one of the few global health plagues that experts are so optimistic about that some have started talking about eradicating the disease.

“I think there’s a lot of room for optimism,” said Philip Welkhoff, director of malaria control programs at the Bill & Melinda Gates Foundation. “In a couple of years, in this very decade, we could really launch an initiative that would reduce cases to zero.”

Last year, China and El Salvador were certified as malaria-free areas, and cases have been reduced by nearly 90 percent in the six countries through which the Mekong flows, including Vietnam and Thailand. By 2025, about 25 countries are expected to have eradicated malaria.

Currently, most infections occur in Africa. Even on that continent, almost 12 million African children received more medicines to prevent malaria in 2020 than in 2019, despite restrictions imposed by the coronavirus pandemic.

However, the arrival of two new vaccines heralds a much bigger change. The first, named Mosquirix, took 35 years to make. It was approved by the World Health Organization last year and could be on sale as early as next year.

A stronger malaria vaccine developed by the Oxford University team that developed AstraZeneca’s COVID-19 vaccine could hit the market in a year or two. This formulation, which has shown up to 80 percent effectiveness in clinical trials, is seen by many experts as the one that could transform the fight against malaria.

And there are other options on the horizon, including an mRNA vaccine being developed by German company BioNTech; monoclonal antibodies that can prevent malaria for six months or more; mosquito nets with long-lasting insecticides or chemicals that paralyze mosquitoes; as well as new ways to catch and kill mosquitoes.

“It’s an exciting time,” said Rose Jalang’o, who led a pilot of the Mosquirix vaccine in Kenya, where it was given to children along with other vaccines.

However, making the world malaria-free will require more than just promising tools. In many African countries, the distribution of vaccines, medicines and bed nets comes with overcoming myriad challenges, including rough terrain, other pressing medical priorities and misinformation.

Although funding for malaria control programs is far more generous than for many other diseases that plague poor countries, resources remain limited. Putting money into an initiative often causes funders to overlook others, fueling competition and sometimes resentment.

The Mosquirix vaccine has taken more than $200 million to develop over more than 30 years, but it is about half as effective as the Oxford vaccine called R21. The first doses of Mosquirix won’t reach African children until late 2023 or early 2024. Supply will be severely limited for a number of reasons and is expected to remain so for years to come.

R21, the second vaccine, seems stronger, cheaper and easier to make. And the Serum Institute of India is poised to produce more than 200 million R21 doses a year.

Some malaria experts say the world needs all available options given the urgent need. But others worry that any dollars going to Mosquirix now are dollars that aren’t being used to develop other tools.

“Funding for existing malaria control efforts is already tight,” said Javier Guzmán, director of global health policy at the Center for Global Development in Washington. “I don’t want to be negative, but a new tool without additional funds essentially implies a sacrifice, an opportunity cost.”

“Move Too Fast”

Malaria is one of the oldest and deadliest infectious diseases. Years of great progress stalled about a decade ago. In 2019, a balance of 229 million new infections and 558,000 deaths remained.

Although the COVID pandemic did not cause malaria infections to skyrocket like tuberculosis, the pandemic reversed a slow downward trend in malaria deaths, which rose to 627,000 in 2020.

Almost all of the people who died from malaria lived in sub-Saharan Africa, where about 80 percent of deaths are children under the age of 5.

Many of the strategies used to fight malaria are outdated but inaccessible to millions. For example, only about half of African children sleep in beds covered with insecticide-impregnated bed nets, and even fewer receive seasonal medication to prevent infection.

Malaria exacerbates social inequalities. It robs children of the ability to fight off other pathogens, overwhelms healthcare systems, and devastates entire communities. An untreated person with malaria can stay sick for six months, giving mosquitoes a chance to spread the parasite to up to 100 other people.

The parasite destroys the body so quickly that when many children are hospitalized, they are in urgent need of a blood transfusion. But blood supplies are often scarce in sub-Saharan Africa, and using a blood bag for a small child can mean half or more is wasted, explained Mary Hamel, who leads the malaria vaccine implementation program at WHO.

“You see a child who’s pale and weak and breathing fast and they’re lying there on the table and there’s nothing you can do,” he described.

“Malaria must be impede; It’s going too fast,” he added.

Mosquirix, the first vaccine against parasites, is a technical milestone. But its effectiveness, at 40 percent, is much lower than scientists expected.

Ideally, the vaccine should be distributed alongside existing control measures such as insecticide-impregnated bed nets and preventive medication, based on data indicating where funds are most needed and delivered by a strong team of health care workers.

“Combined with the right tool, you can make a much bigger impact,” said Thomas Breuer, director of global health at GlaxoSmithKline, which makes the Mosquirix vaccine.

However, mistrust of vaccines is high in many African countries. In a poll, about half of people in Niger and the Democratic Republic of the Congo said they would not trust a malaria vaccine.

Also, Mosquirix was to be given in four doses, the first at 5 months of age and the fourth at 18 months of age. But children older than 18 months rarely receive further vaccinations, and many African parents face major logistical hurdles to get their children to a clinic.

Limited resources

Compared to the billions of dollars being spent on COVID vaccines, funding malaria is a pittance. The Gates Foundation spends about $270 million annually to fight the disease, not counting its contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Scarce resources mean that people – and organizations – end up choosing their preferred strategies. Some argue that controlling the mosquito population is the most logical way, while others promote vaccination, with some saying monoclonal antibodies are the way forward.

In such a competitive environment, Mosquirix is ​​not positioned as a clear winner.

“Deploying an expensive, not-so-effective and short-lived tool may not be the best strategy to start with,” said Scott Filler, director of malaria control programs for the Global Fund, which supports more than half of the malaria control programs in the world.

Perhaps the money would be better spent increasing the use of bed nets or ensuring people have access to basic health care like malaria testing, treatment and surveillance, Filler suggested.

However, other experts believe that given the devastation caused by malaria, a low-potency vaccine is better than none.

“We have this vaccine, which has been tested really extensively, more than any other vaccine before it was approved,” said Michael Anderson, who was director-general of the UK’s Department for International Development and now runs MedAccess, a not-for-profit organization funded for profit becomes the British government.

The R21 vaccine has cost less than $100 million to develop. If regulators move at the same speed they’ve shown with COVID-19 vaccines, it could be licensed a few months after researchers deliver final data later this year.

Many parents in Africa are looking forward to a vaccine. In Kisumu, Abdullah is determined to vaccinate her two-year-old daughter, who has had malaria before, to protect her from the disease that has clouded her own childhood.

“I would go to her immediately,” he assured. “In fact, I would choose that before deciding on the COVID-19 vaccine.”