Bringing malaria elimination within reach

M. Henley/ WHO 2018

Your organization, PATH, is a key partner in one of the most exciting developments in combating malaria, the soon to be launched Malaria Vaccine Implementation Programme (MVIP) that will make the RTS,S malaria vaccine available for young children in selected areas of 3 African countries. Why is PATH part of this endeavour?

PATH has been involved in RTS,S development from the very early days, going back to the turn of the century; in fact, the first malaria project at PATH was the Malaria Vaccine Initiative. We have a good mix of talents and experience in vaccine development, from earlier-stage developmental work through regulatory networks and vaccine introduction, scale-up and evaluation. PATH has also worked on other key vaccine development projects, such as meningococcal vaccine and yellow fever.

We have a strong institutional commitment to the RTS,S vaccine, and we are moving into an important phase with the pilot introduction. PATH is involved in technical support and looking at, for example, how vaccine introduction might affect health utilization issues such as uptake or use of other malaria interventions in the pilot communities. It is an exciting time in malaria vaccine development. We used to say we were waiting for the vaccine, and we actually now have one.

The RTS,S malaria vaccine has been in the works for more than 3 decades – why is developing a vaccine for this disease so challenging?

The malaria parasite is a relatively complex organism, compared to some of the other organisms for which we do have vaccines; the parasite has over 5000 genes, whereas, for example, the measles virus has about 6. It also has a complex life cycle that takes place both in people and in mosquitoes. The development of immunity to malaria is equally complex. It occurs over a relatively long period of time and is partial in the sense that people, even with good immunity, still get infected with the parasite although they may not suffer symptoms.

Beyond complex biological challenges, developing a malaria vaccine has also been a research challenge because this is not a vaccine for which we see an easy commercial source of revenue once developed. Malaria is a problem of the poor and the underserved, and while there is a great need, there is not a straightforward business case for the vaccine in the developed world. We have a strong private sector partner, GlaxoSmithKline, which has shown a long-standing commitment to this effort and is providing 10 million doses of the vaccine for the pilot in the selected areas of Ghana, Kenya and Malawi.

Besides malaria, you are an expert on a range of other major diseases and health issues. Based on your experiences, what are the factors for success in preventing disease and promoting health?

Having a commitment to developing new tools, approaches and strategies as you go along because tackling disease is a moving target and there are always new challenges coming up. Equally important is having the health system capacity to deliver those tools and strategies to the populations in need. Finally, a commitment to continue to invest in understanding new ways to do things, to have that commitment to research and keeping in front of the disease.

Through your various roles in global public health governance, you have witnessed huge gains in fighting malaria, particularly over the 2000 to 2015 period. However, as WHO reported in 2017, the global response to malaria has stalled. What is needed to get the response back on track?

This is a question everyone is thinking a lot about. First, it is important to say that we have made enormous progress in fighting malaria. We are in a very different world from when I started, when we had basically no prevention tools and one failing malaria drug, chloroquine. That said, while we have made great progress, there does seem to be a plateauing, or even a slight regression, in some areas. With malaria, you cannot back off and focus elsewhere. We have to keep up malaria control activities on all fronts.

I believe there are additional gains to be made with our current tools and resources, through being more tailored and focused in how we deliver and doing a deep dive into problematic high-burden areas. We will also continue to need that commitment to invest in developing new tools and finding the resources to take us to that next level. The malaria community is pretty much aware of this now, and I think WHO has done a good job of raising this issue, and bringing together the partners, led by the national programmes, to begin a renewed response involving all stakeholders.

Speaking of new tools, in Zambia, PATH is partnering with a data visualization foundation to help support the country's malaria elimination efforts. Tell us more about this initiative and why is data – and making it visual – vital to reaching zero cases of malaria?

One of the core pillars of the WHO Global Technical Strategy for Malaria 2016-2030 is having surveillance as an intervention. In Zambia, what we are doing is supporting the national programme in bringing together quality data to make decisions in a timely way to help decide what to do, where to do it and how to do it; in other words, information for action. The project is called Visualize No Malaria and it represents a strong partnership between the Zambian Government, the Ministry of Health, PATH and private-sector partners who work in the data management, collection and visualization space.

The key thing with Visualize No Malaria is that the data visualization tools are designed by the front-line workers who are using the tools. This approach is one of the most exciting areas in the near term for malaria because this is something that we can do now, and it is an area of great change with the possibility of rapid improvement. I am optimistic that this is part of the armamentarium that we can bring forward to continue to reduce malaria morbidity and mortality.

You recently participated in your last meeting of the Malaria Policy Advisory Committee (MPAC). After 7 years as a MPAC member, how do you feel as you step away from this role?

It has been a rewarding experience. Many people who go into public health want to be engaged in activities that generate good evidence and to participate in the policy-making process to help do a better job of preventing morbidity and mortality. MPAC has been a wonderful opportunity to be part of that process and to stay abreast of the latest developments, as well as to learn from my colleagues.

Importantly, MPAC has put the WHO malaria policy-making process in a much more transparent light. It has continued to examine itself over the years and to make improvements in how it works. There are aspects that still need to be addressed and will continue to be worked on moving forward, but I think that openness, that transparency and that commitment to trying to do this in the best way possible, with good input from all aspects of the community, is a successful way forward.