Letter to malaria partners (December 2019)

Dear malaria partners,

As the end of 2019 draws near, I would like to take a moment to reflect on our work in the WHO Global Malaria Programme – the bright spots, challenges and lessons learned. This latest edition of my bi-annual “Letter to partners” will cover updates and developments since June, when I issued my last message from the E-2020 global forum. 

I would like to thank our partners for their ongoing support and collaboration in the fight against malaria and, above all, countries for their leadership and efforts to beat back this disease.

A reminder that you can receive regular updates on our work by subscribing to our electronic newsletter.

I wish you all a very happy holiday and new year.

Best wishes,
Pedro

Topics covered in this letter

– World malaria report 2019
– “High burden high impact”
– RTS,S malaria vaccine pilot programme
– Progress against P. falciparum malaria in the Greater Mekong
– Key findings from WHO’s advisory group on malaria eradication
– WHO-hosted forum on eradication
– New WHO position statement on non-pharmaceutical forms of artemisinin

World malaria report 2019

Our latest World malaria report documents successes in many countries, particularly those with a low burden of malaria. At least 10 countries that are part of WHO’s “ E-2020 initiative” are on track to reach the 2020 elimination milestone of our global technical strategy. Two countries with a very high burden of malaria, India and Uganda, reported significant reductions in their malaria caseload.

However, for the 4^th year in a row, progress towards critical targets of the global strategy has plateaued. The report showed no improvement in malaria case incidence in the period 2014 to 2018, and little progress in reducing death rates.

Inadequate funding remains a major obstacle. In 2018, malaria investments reached an estimated US$ 2.7 billion, falling far short of the US$ 5 billion funding target of our global strategy. This has resulted in significant coverage gaps of core malaria interventions.

“High burden to high impact”

How can countries and their development partners achieve greater impact within a constrained resource envelope? Meeting the global targets for 2025 and beyond will require a new mindset. Doing more of the same will not bring us to a different place than where we stand today.

The “ High burden to high impact” (HBHI) approach, catalysed in 2018 by WHO and the RBM Partnership to End Malaria, provides a framework that can help guide future success. It is founded upon 4 pillars:

• political will to reduce the toll of malaria;
• strategic information to drive impact;
• better guidance, policies and strategies;
• a coordinated national malaria response.

Over the last year, I have been extremely encouraged to see countries embrace this effort. To date, 10 countries with a high burden of malaria – including 9 in Africa, plus India – have adopted the HBHI approach. With support from WHO and partners, they are collecting and analyzing data to better understand the geographic distribution of malaria and the impact of specific actions. These analyses will help them use available resources in a more effective and equitable way.

Recognizing the heterogeneity of malaria within national borders, HBHI countries are moving away from a one-size-fits all approach. Instead of applying the same approach everywhere, they are tailoring different mixes of WHO-recommended tools – vector control, chemoprevention, diagnostic testing, treatment – to local malaria contexts. This is what successful malaria control strategies will look like in the coming months and years.

Within the Global Malaria Programme, we are adapting our policy guidance to better support countries in their efforts to prioritize scarce resources and select the right mix of interventions for a given context.

Spotlight on pregnant women and young children

The World malaria report 2019 brings back the focus to pregnant women and young children in Africa, the 2 groups that bear the brunt of the disease. It reminds us that our number one imperative – from a malaria control perspective, and an ethical one – is to reduce cases and deaths among the most vulnerable.

The use antimalarial medicines for prevention – known as “chemoprevention” – is a WHO strategy for reducing malaria-related disease and death in sub-Saharan Africa. We are committed to expanding its use as a quick and effective way to save lives among populations at greatest risk.

For pregnant women, WHO recommends at least 3 or more doses of intermittent preventive treatment in pregnancy (IPTp). The preventive therapy is provided at antenatal care facilities at monthly intervals, starting as early as possible in the 2^nd trimester. Our latest World malaria report finds that approximately one third of pregnant women in sub-Saharan Africa received 3 or more doses of IPTp in 2018, up from 22% the year before.

In Africa’s Sahel subregion, seasonal malaria chemoprevention (SMC) is recommended during the high-transmission rainy season. It has been shown to have a 75% protective effect against malaria in children under the age of 5. In 2018, 62% of children who were eligible for this intervention received it.

This year, Sierra Leone became the first country in Africa to roll out intermittent preventive treatment in infants (IPTi), a strategy that involves providing antimalarial medicines to very young children through a country’s immunization platform. Using an existing platform – the Expanded Programme on Immunization – to deliver preventive malaria therapy is an excellent example of integration. It is the type of new avenue we will need to pursue as we strengthen our response to the disease.

In recent years, Unitaid has played a critical role in financing efforts by WHO and partners to scale up IPTp and SMC for pregnant women and children in Africa. We welcome their latest drive, announced earlier this month, to accelerate the adoption and scale-up of IPTi.

RTS,S malaria vaccine pilot programme fully under way

In September, Kenya introduced the RTS,S malaria vaccine, joining Ghana and Malawi as pioneers of a landmark pilot programme coordinated by WHO. Thirty years in the making, the vaccine – known as RTS,S – will be made available to 360 000 children annually in selected areas of moderate and high malaria transmission. Evidence and experience from the programe will inform future WHO policy decisions around the potential wider deployment of the vaccine in Africa.

The pilot programme is supported through an unprecedented collaboration between 3 key global health funding bodies: Gavi, the Vaccine Alliance, the Global Fund and Unitaid. The 3 agencies provided initial financing for the first phase of the programme, from 2017-2020, and recently committed additional resources to see it through completion.

In view of the global burden of malaria, and the considerable life-saving potential of this vaccine, members of the Gavi Board took a strategic decision at a recent meeting to explore options that would prevent a disruption in the supply of the vaccine ahead of a WHO policy recommendation. As stated in a recent press release, Gavi has committed to work with partners “to identify, as soon as possible, third parties to share the risk of investing in continued production of RTS,S.” WHO welcomes this decision and commends Gavi for its leadership on this critical issue.

Continued progress against P. falciparum malaria in the Greater Mekong

Countries of the Greater Mekong Subregion (GMS) continue to make excellent progress in their efforts to stamp our malaria. Our annual bulletin, published this week, finds that cases and deaths in the 6 GMS countries fell by 74% and 95%, respectively, between 2012 and 2018.

Notably, there has been a substantial decline in cases of P. falciparum malaria – a primary target in view of the ongoing threat posed by drug resistance. According to the bulletin, P. falciparum cases fell by 65% in the first half of 2019 compared to the corresponding period in the previous year – the steepest decline seen to date.

Drug-resistant parasites continue to circulate in this Subregion, but they have not spread beyond the Greater Mekong. When first-line treatments fail, alternative and efficacious drug regimens remain available. As such, the number of cases in the Subregion continues to decline, and countries are closer than ever to eliminating P. falciparum malaria.

Several GMS countries have reported significant national milestones. For the first time in the country’s history, Cambodia reported zero malaria-related deaths. China reported its third consecutive year of zero indigenous cases of the disease. Thailand has also made impressive gains, with a 38% decline in P. falciparum cases seen between 2017 and 2018.

Key findings from WHO’s advisory group on malaria eradication

In 2016, at the request of the former Director-General, Dr Margaret Chan, WHO established a Strategic advisory group to tackle the big question of malaria eradication – a topic that sparks passions, opinions, excitement and concerns. Dr Chan felt that WHO should have a position on eradication that was rooted in a deep analysis of past and future malaria trends, grounded in the best available evidence.

Over a period of 3 years, members of the group – comprised of leading scientists and public health experts from around the world – came together to advise WHO on what the malaria landscape might look like in the future, as well as the feasibility and expected cost of eradication. In August, they published a set of key findings and recommendations, and a detailed report of their work is expected early next year.

Members of the advisory group reaffirmed that malaria eradication is a goal worth pursuing, and that it would likely save millions of lives and generate a substantial return on investment. However, with currently available tools, they were unable to define a realistic target date for eradication, nor calculate what such an effort would cost.

The advisory group identified a renewed R&D agenda as one of the highest priorities in efforts to achieve the vision of a malaria-free. Other priorities include access to affordable, people-centered health services; a reliable, rapid and accurate surveillance and response system; and the development of national and subnational strategies tailored to local conditions.

WHO forum on malaria eradication

In September, members of the international malaria community gathered in Geneva for a WHO-hosted forum on “Rising to the challenge of malaria eradication.” Opening the forum, WHO Director-General, Dr Tedros Adhanom Ghebreyesus, described malaria eradication as “one of the ultimate public health goals for a century” and noted that it is also proving to be one of the “greatest challenges.”

Echoing the call from our advisory group, Dr Tedros encouraged donors to ramp up investment in the research and development of new malaria-fighting tools and approaches. He cited the Malaria Eradication Research Agenda as a useful starting point to guide R&D investment in the development of new, transformative tools.

The forum also provided an opportunity to present the findings of a new report by the Lancet Commission on malaria eradication. A commentary by Dr Tedros ran alongside this report in the September edition of the medical journal.

New WHO position statement on non-pharmaceutical forms of artemisinin

For those living in malaria-affected countries, artemisinin-based combination therapies – the most effective and widely used antimalarial treatments – are not always readily accessible. In some areas, the medicines are only available at high prices or are of sub-standard quality.

These challenges have given rise, in recent years, to the promotion of a range of products made from Artemisia plant material – such as teas, tablets and capsules – as affordable and effective medicines against malaria.

This year, WHO embarked on an extensive evidence review on the effectiveness of non-pharmaceutical forms of Artemisia. Following this process, we issued a new position statement with a clear message: “WHO does not support the promotion or use of Artemisia plant material in any form for the prevention or treatment of malaria.” Our position is explained in detail in this report.