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Is malaria getting bigger and badder?

By Sungano Mharakurwa Moderator | 21 Jul, 2017

To emphasize the need for extending the repertoire malaria intervention "weapons" as much as possible, Robert Gebelhoff argues that malaria is getting bigger and better (https://www.washingtonpost.com/news/in-theory/wp/2017/02/03/malaria-is-gettin...). The emergence of parasite resistance to antimalarial drugs and vector resistance to insecticides (see attached) certainly causes concern. Hopefully this time, unlike the 1950s, funding levels do not falter as more countries strive towards elimination.



Pierre Bush, PhD Moderator Replied at 11:55 AM, 28 Jul 2017

Thank you Sungano for these informative resources. Indeed, looking at the pattern in which the resistance to Artimisin Combination Therapy (ACT) by Plasmodium falciparum in the Greater Mekong Area has been growing, the identification of new drugs to back the ACTS is a fierce urgency of now. No time to waste.
Highest regards.

Maimunat Alex-Adeomi Moderator Replied at 12:33 PM, 28 Jul 2017

Thank for you highlighting this again Sungano and yes Pierre, the emerging resistance to ACTs is definitely cause for concern.

I believe other than funding and political will issues, there general sense of instability in many regions and countries of the world, add to the challenges with achieving malaria control.


Sungano Mharakurwa Moderator Replied at 12:55 PM, 28 Jul 2017

Thanks Pierre. What is concerning is that according to both the Global Fund (https://www.theglobalfund.org/en/malaria/) and the World Health Organization (http://www.who.int/mediacentre/news/releases/2016/malaria-control-africa/en/), while malaria funding increased considerably between 2000 and 2010, it has since levelled off. Estimates are that current global funding levels ($2.9 billion per year) are less than half of what is required to maintain gains against the disease. With emerging vector insecticide resistance and parasite drug resistance, there may be need for an appeal to further strengthen funding levels, or else humanity may have stirred up a hornets' nest. The WHO indicates that if global targets against malaria are to be met, funding from both national and international sources must be increased substantially (http://www.who.int/mediacentre/news/releases/2016/malaria-control-africa/en/).

NIRMAL GHIMIRE Replied at 10:24 AM, 29 Jul 2017

Is malaria treated free of cost ? Which are the countries where it's
treated free of cost?

pascal verhoeven Replied at 2:06 AM, 31 Jul 2017

Just my thoughts (for some time already)
1 quote "New antimalarial compounds will not become widely available for
several more years" unquote (White NJ et al)
2 containment of Artemisinin Resistance in pf parasite has not focussed
sufficiently on an effective implementation of *regional* drug policies to
treat confirmed cases using alternating ACTs throughout region (i.e.
alternate use of mefloquine, piperaquine, lumefrantine from one season to
the next) supported by efficacy studies and prolonged dosage schedules 6
days instead of 3 days in case of delayed parasite clearance.
3 there are still high levels of overuse of ACTs [of probable cases] in
high burden countries which is perpetuated where the focus has been, and
still is overly on availability of (free/subsidized) ACTs; where ACTs are
used more than parasitological tests are done.
4 the spread of artemisinin resistance, now even by hard selective sweeps
across borders is obviously a growing and major threat to the elimination
of malaria in the GMS region, yet the regional artemisinin resistance grant
(RAI) shifted to a regional malaria elimination grant (which come to think
of it, appears to me rather circular). This new WHO approach may not be
cutting it nor to be shifting paradigms around elimination and drug

pascal verhoeven
(living in Laos)

Manuel Lluberas Replied at 12:27 PM, 31 Jul 2017

Malaria continues to thrive under the current conditions and many countries have seen a resurgence of the disease while the WHO remains retiscent about deploying tested vector control tools like LSM. The WHO Larval Source Management and the "New Tool for Malaria Control in Africa" published earlier this year consider larval source management and larviciding as effective only when larval sources are "few, fixed and findable." When asked about the value of Fred Soper's work in Brazil (See "Anopheles gambiae in Brazil: 1930 - 1940," the argument from many at WHO is that what Soper did could not be replicated. I don't buy that. We cannot use what Soper had available, but we need to keep in mind that Soper eradicate the malaria vector from an area the size of Togo, West Africa with non of today's technology or materials. We have satellite imagery that can detect mosquitoes sources (I am working on a project in Asia calibrating those images) and we have drones that can deliver in a few hours what took Soper several days or weeks.

While new diagnostic and treatment methods are needed, the world needs mosquito control. Ronald Ross (ca 1900) argued that malaria would continue until the world got serious about controling the mosquito. A century later, the mosquito continues to be ignored.

Sungano Mharakurwa Moderator Replied at 1:23 PM, 31 Jul 2017

Hi Nirmal. Thank you for your question on free malaria treatment. Practice is bound to vary by country, or even intra-country, depending on local resources and(or) programmes (https://www.ncbi.nlm.nih.gov/pubmed/28548247). However, free treatment is likely much less common, which may pose coverage challenges, though some countries at least provide subsidies. Every approach also has its pros and cons.

Attached resources:

Sungano Mharakurwa Moderator Replied at 1:32 PM, 31 Jul 2017

Many thanks Pascal for pointing out these important gaps and instrumental implementation strategies. Strategies for containment of artemisinin resistance are paramount to winning the malaria battle.

Sungano Mharakurwa Moderator Replied at 1:46 PM, 31 Jul 2017

Hi Manuel. Your reference to Soper's work and how he achieved vector elimination with much less than what we have today is inspiring. I have attached a couple more resources on this.

Attached resources:

Manuel Lluberas Replied at 2:31 PM, 31 Jul 2017

Thanks for your kind words and documents, Sungano. I am always amazed and sometimes amused at the approach taken to control a mosquito-borne disease. Soper would have been amazed at today's technology, especially remote sensing and the use of drones for surveillance and control of mosquitoes. The surprising thing is that when you ask at a meeting of malaria or dengue control workers how many know of Soper or Israel Kligler, very few people raise their hands. Perhaps they are shy and don't want to respond, but there are way too many that don't know these names (especially recent graduates). More troubling, the few who know Soper and his work and can affect some basic changes in global mosquito control strategies consider his work "unreplicable" and go so far as to consider larval source management and larviciding useful "only when the larval sites are few, fixed and findable." Frankly, I cannot think of any of the 100+ countries that eliminated malaria and have kept it out that did so without LSM and larviciding.

WHO needs to review WHO's Offset Publications No. 1 & 66.

No 1: Manual of LArval Control Operations in Malaria Programs
No. 66: Environmental Management for Mosquito Control; with Special Emphasis on Malaria Vectors

The "new" LSM Manual should have included a good portion of these, but it did not.

The mentality dates back to Ronald Ross. Around 1900, he said something like: "Malaria will continue to afflict millions until the mosquito is taken seriously." During the contruction of the Panama Canal, members of the Isthmian Canal Commission (1903) voiced their concern that “To spend time and money chasing after mosquitoes … would be to squander time and money in a most irresponsible fashion.” William Gorgas proved them wrong.

Unfortunately, these names, and the work of a few others like them have fallen off the pages of public health history books; except for a handful of people who continue to try raise them from obscurity.

Sungano Mharakurwa Moderator Replied at 8:01 AM, 1 Aug 2017

Quite clearly, one lesson from successful, as well as failed, malaria elimination campaigns is the importance of attacking both the parasite and the vector(s). Slackening anti-vector measures would seem a repeat of the same mistakes already learned the hard way long ago. The other point of course is the vast diversity in local ecological, social, political, pharmaceutical, donor and economic conditions, rendering it impossible to have a one-size-fits-all. The aforementioned array of elements that can determine success of elimination efforts tends to be tenuous and varies by location and time. Be that as it may, it seems the present time is when everything is relatively well lined up, including even commendable cross-border/regional initiatives. With so much more in the arsenal of interventions, it is really a challenge to our generation to better or at least match what was accomplished before with much less, be it vector eradication or anophelism without malaria. As the battle rages on, at least success stories such as The Gambia (https://www.voanews.com/a/gambia-funding-drive-aim-first-sub-saharan-nation-f...) and others (as also in "Eliminating Malaria" resource) are encouraging. Many thanks

Attached resources:

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