Progress towards global malaria targets has stalled in recent years, and the COVID-19 pandemic has posed a serious threat to malaria responses worldwide, but a number of countries are nearing the goal of zero cases of malaria, said WHO, in a forum convened just ahead of World Malaria Day on 25 April. 

The forum Reaching Zero: Virtual Forum on Malaria Elimination  saw the launch of a new new initiative – E2025 –  to halt transmission of the disease in 25 countries by 2025 co-sponsored by the RBM Partnership to End Malaria.

Meanwhile, the world’s first malaria vaccine has reduced severe malaria by about one-third among the 650,000 children in Ghana, Kenya, and Malawi, who have received the jab in a late stage clinical trial. That makes it a “promising additional tool in malaria prevention,” said Dr Matshidiso Moeti, WHO Regional Director of Africa, at the WHO forum on Wednesday. 

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The preventable and treatable disease kills over 400,000 people every year across 87 countries. The WHO African Region accounts for 94% of all malaria cases and deaths worldwide, with deaths in children under the age of five in sub-Saharan Africa constituting the majority of global deaths from malaria.

Although progress towards critical targets of the global malaria strategy has plateaued, particularly in high burden countries, 24 countries have reported zero indigenous malaria cases for three or more years between 2000 and 2020.

The number of countries with less than 1,000 malaria cases has more than doubled since 2000, from 14 to 34 and more countries than ever before are within reach of zero malaria, said the panelists at the event.

“These countries have shown that malaria elimination is a viable goal for all countries, no matter how far they may be from the ultimate target,” said Dr Tedros Adhanom Ghebreyesus, WHO Director General, at the forum. 

Zero Malaria Initiative

In 2017, WHO launched the E-2020 initiative to support a group of countries to achieve zero indigenous cases of malaria by 2020. Some 21 countries across five regions were identified as having the potential to reach the milestone of eliminating malaria.

Of the 21 countries, eight reported zero cases of malaria, as of April 2021. The countries included, Algeria, Belize, Cabo Verde, China, El Salvador, Iran, Malaysia, and Paraguay. 

In February 2021, El Salvador became the first Central American country to achieve the milestone of being classified as malaria-free. The number of cases fell from more than 9,000 in 1990 to less than 30 in 2010. 

The long term commitment to malaria elimination involved establishing a large network of vector control personnel, labs, and over 3,000 community health workers responsible for case detection. 

Cabo Verde previously experienced severe malaria epidemics and came close to eliminating the disease twice before successfully achieving three consecutive years of zero indigenous cases in January 2021. 

The government established a five year national strategic malaria plan in 2009 and invested in the expansion of diagnostic and early treatment services, which were provided for free, along with capacity building for investigating detected cases. 

“Success is driven by political commitment, which is translated into sustained funding, it is driven by a health system that leaves no one behind, that ensures good diagnosis and treatment…without financial hardship,” said Dr Pedro Alonso, Director of the WHO Global Malaria Programme. 

The key elements shared by countries that have eliminated malaria also include robust health information systems and surveillance systems to track cases and cross-border collaboration to prevent the disease from being transmitted across international borders, according to the new WHO report on the E-2020 initiative. 

A number of other countries also made progress towards zero malaria transmission, with Timor-Leste reporting only 1 indigenous case, and three countries recording fewer than 100 cases. 

In addition, six countries in Southeast Asia have advanced towards the target of elimination by 2030, with a 97% fall in the reported number of cases between 2000 and 2020. 

Challenges to Reaching Zero Malaria

Several persistent issues challenge efforts to eliminate malaria, outlined the new WHO report on the E-2020 initiative. Drug and insecticide resistance, along with imported cases of malaria threaten to undermine the goal of becoming malaria-free. 

Resistance to antimalarial drugs is driven by counterfeit or substandard treatments and the unregulated administration of the drugs. Drug resistance poses a serious threat to the effective control of malaria and it increases morbidity and mortality.

Insecticide-based vector control is a cornerstone of the global fight against malaria, however, insecticide resistance is widespread in all major malaria vectors in high burden countries, according to a WHO report. Resistance to at least one of the four insecticide classes was detected in 73 of the 81 malaria endemic countries, as of 2018. 

In addition, numerous countries have struggled with reducing imported cases of malaria, which threatens the ability of countries to prevent onward transmission and maintain zero indigenous cases. This is particularly a challenge for countries surrounded by other endemic countries with porous borders. For example, in recent years, more than 80% of cases detected in Iran have been imported, largely linked to the frequent cross-border movement of migrant workers.

E-2025 Initiative

The E-2025 is a new elimination initiative that builds on the foundation of the E-2020. It includes a new cohort of 25 countries that are on the cusp of eliminating malaria. 

“At least a further 25 countries that still have malaria transmission today could potentially interrupt transmission in the next five years. That would be a massive global public health achievement,” said Alonso. 

The set of countries includes all E-2020 member countries that did not yet receive malaria-free certification, along with eight new countries: Guatemala, Honduras, Dominican Republic, Panama, Sao Tome and Principe, Vanuatu, Thailand, and the Democratic People’s Republic of Korea. 

The new countries were selected based on four criteria: the establishment of a government-endorsed elimination plan; meeting the threshold of malaria case reductions in recent years; having the capacity of malaria surveillance and a designated governmental agency responsible for malaria elimination; and being selected by the WHO Malaria Elimination Oversight Committee. 

The E-2025 countries will receive technical and on-the-ground support by WHO and its partners. In return, they are expected to audit their elimination programmes annually, participate in elimination forums, conduct surveillance assessments, and share malaria case data periodically. 

“Malaria…is a very unforgiving disease. You’re either winning or you’re losing,” said Peter Sands, Executive Director of The Global Fund to Fight AIDS, Tuberculosis and Malaria. “In these countries where we have already made such progress towards elimination, if we take the foot off the accelerator now, we will go backwards. So we must continue to drive towards elimination.”

Impact of COVID-19 on Malaria Programmes

During the COVID-19 pandemic, human and financial resources were diverted from national malaria programmes to tackle COVID-19. This, along with nationwide lockdowns, delayed the delivery of malaria preventative measures and the provision of treatment services. 

However, the impact of COVID-19 on malaria cases in 2020 didn’t reach the worst case scenario in WHO predictions conducted early on in the pandemic. The modelling predicted that there could be a doubling in malaria cases due to interruptions in mosquito net campaigns and treatment provision.

“Most of the mosquito net campaigns took place as planned, or with some slight delay, so over 160 million mosquito nets were distributed despite COVID,” said Dr Melanie Renshaw, Co-chair of the Country and Regional Support Committee of the RBM Partnership to End Malaria. 

In addition, more children than ever before received seasonal malaria chemoprevention last year. 

The high level advocacy from WHO, strong leadership from governments, the prioritization of malaria, and support from partners ensured that the disruptions were as minimal as possible, said speakers at a press briefing following the forum. 

“We believe we avoided that worst catastrophe of a doubling of cases but we certainly will see…when the data are finalised, that there were increases in malaria deaths as a result of the COVID pandemic, largely due to service disruptions…in case management,” said Renshaw.

“[But] of course we’re not out of the woods yet,” she added. 

More than a year into the pandemic and interruptions in programmes persist. Approximately one third of malaria programmes reported serious disruptions in prevention, diagnosis, and treatment services in the first three months of 2021, according to a recent Global Fund survey.

Increasingly, community health workers will be needed for COVID-19 vaccination programmes, potentially at the expense of timely diagnosis and treatment of malaria. This could drive up mortality. 

“Our community health workers are the absolute fulcrum of everything that happens with malaria, they’re the ones that diagnose, they’re the ones that treat, they’re the ones that mobilise the community, and understand what is really going on,” said Sands. 

The current biggest challenge is keeping the political focus on malaria, said the speakers. 

“We need to continue to keep very high on the agenda the importance of sustaining malaria and COVID Prevention at the same time,” said Renshaw. 

RTS,S Malaria Vaccine is a “Promising Additional Tool” 

Meanwhile, the world’s first malaria vaccine, administered to some 650,000 children in Ghana, Kenya, and Malawi, has demonstrated comparatively high efficacy rates in reducing malaria in large scale late stage clinical trials, including life-threatening malaria in young children, hospital admissions, and the need for blood transfusions, said Moeti.

The four dose vaccine reduced malaria by 39% in children aged 5-17 months, which is equivalent to preventing 4 in 10 malaria cases and it reduced severe malaria by 31.5%.

“This vaccine may be key to making malaria prevention more equitable, and to saving more lives,” said Dr Kate O’Brien, WHO Director of the Department of Immunization, Vaccines and Biologicals, in a press release published on Tuesday. 

Global advisory bodies are expected to convene on 6 October to review RTS,S data and evidence from the pilot programme to determine whether to recommend broader use of the vaccine. 

“We feel very reassured by what we are seeing up to now,” said Alonso. “It is not a perfect vaccine, but it is one that can prevent a significant number of cases and a significant number of deaths.”

“And if such a recommendation takes place, it would be a truly historical moment. The world has been looking for a malaria vaccine for 100 years,” Alonso added. 

In over 30 years, less than one billion dollars were invested to develop a malaria vaccine. In comparison, approximately US$40 billion was used to fund COVID-19 vaccines in a year, resulting in four licensed vaccines within 10 months.

While a malaria vaccine is biologically “infinitely more complex than a COVID-19 vaccine,” the difference in the scale of effort and investment is huge, Alonso said.

“For a large part of the world, and particularly sub-Saharan Africa, malaria – which they’ve had to live with for the last 10,000 years – is like COVID-19 to the rest of us, every year,” said Alonso. 

The RTS,S vaccine is the first vaccine developed to address a disease that impacts over 40% of the world’s population that live in malaria endemic countries and kills more than 400,000 people annually.

Malaria is often referred to as a poverty related disease, with marginalized communities, children under 5 years of age, pregnant women and patients with HIV/AIDS, as well as migrants at a higher risk of contracting it. 

The prioritization of malaria on the political agenda should also be accompanied by investments in innovation to improve equity in health systems, said speakers at the press briefing on Wednesday. 

Malaria Vaccines “Critical” to Speed Up Progress Towards Zero Malaria

Due to the recent plateau in progress towards global and regional malaria targets, “new tools are urgently needed – and malaria vaccines must be a critical component of the overall toolkit,” said Alonso. 

While new cases in the African region dropped by over 9% every five years between 2000 and 2015, in the last five years this progress has stalled, according to Moeti.

As of 2019, one in three households in the region didn’t have an insecticide treated bed net and nearly half of children under five didn’t sleep under a net. Two thirds of pregnant women didn’t receive malaria preventive treatment, as a result, 11 million pregnant women contracted malaria and 820,000 newborns had a low birth weight.

“Every year that we let malaria continue to spread, health and development suffer,” Moeti said.

Image Credits: WHO, WHO.