Q&A on malaria eradication

Why did WHO establish a Strategic Advisory Group on malaria eradication (SAGme)?

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 and that it should be based on a thorough and authoritative study rooted in a deep analysis of past and future malaria trends. The group, made up of scientists and public health experts from around the world, came together to advise WHO on what malaria might look like in the future as well as the feasibility of eradication.

What is WHO’s current position on malaria eradication?

Remember that WHO embraced the goal of malaria eradication soon after it was founded in 1948. In 1955, a first Global Malaria Eradication Programme (GMEP) was launched. This commitment to eradication was reaffirmed in a World Health Assembly resolution of 1969, and later reinforced in 2015 through the Assembly’s endorsement of the Global technical strategy for malaria 2016-2030 (GTS). It clearly spells out the vision of a malaria-free world.

What were the group’s main findings about malaria eradication?

The key finding is that a malaria-free world would mean millions of lives saved and a return on investment of billions of dollars. Global megatrends related to climate, urbanisation, agricultural use patterns, electrification mean that malaria will be radically reduced in many areas but remain entrenched in others. Yet even with our most positive projections, if we use our current tools to fight malaria, we will still have 11 million cases of malaria in Africa in 2050. No one can formulate a precise and reliable plan for the eradication of human malaria nor calculate what it will cost. SAGme concluded that, especially with the stalling of process over the past 2 years, we must get the world back on track to meet the GTS targets. To do this, we need a renewed drive towards research and development, including on malaria vaccines and other approaches and tools. We also need political leaders to ensure everyone has access to affordable health care. And we must invest in robust and agile surveillance systems to detect changes in malaria transmission so that we can better target the response. Eradication is still the global vision.

What is the difference between elimination and eradication?

This definition has changed over the years. Currently, we call elimination the interruption of transmission in a given geographical area; usually we refer to a country. Eradication means that all countries have eliminated malaria and there is complete interruption of malaria transmission globally, with zero cases across the globe.

Does WHO’s advisory group think that malaria can be truly eradicated, as is the case with smallpox?

The answer is yes. There is no specific biological or environmental barrier to malaria eradication. However, do we have the tools, programmes and financing that could actually drive an eradication effort now? The answer is no. 

A successful eradication effort will require tools that we don’t have today. This speaks to the critical importance of an accelerated research and development agenda.

Why is it taking so long to eradicate malaria?

We are fighting a very complex parasite - one that can be transmitted by certain mosquito vectors very efficiently. Malaria roots itself in the heartland of Africa and affects some of the harder-to-reach and more impoverished populations. To date, the disease has received insufficient attention in the research and development space, and insufficient investment to roll out available tools, particularly in countries with weak health systems.

What is the WHO doing now to fight malaria in areas hardest hit by malaria?

WHO and the RBM Partnership to End Malaria are driving the country-led High burden to high impact (HBHI) approach. It will initially focus on getting the 11 highest burden counties - 10 of which are in Africa - back on track to achieve the GTS targets for 2025. By taking this approach, countries will enable real impact in the fight against malaria. The concrete outcomes we are aiming for include more resources freed up by political leaders, better use of information, stronger technical guidance and a more coordinated response to malaria. We will roll out the HBHI approach to all malarious countries in Africa as we progress towards a malaria-free continent.

Some experts think that we should have a target date for the malaria eradication goal as we do for some other public health goals. Why can’t we work towards a target date to eradicate malaria?

If we consider smallpox, the burden of the disease was relatively low when WHO launched an eradication campaign in 1967. At the time, we had a highly efficacious vaccine and could actually foresee an end date. 

When the polio eradication campaign was launched in 1988, there were an estimated 330 000 cases of the disease and we had a highly effective vaccine. The campaign originally had a 12- or 15-year timeline. However, 30 years later, despite massive progress, the job has still not been completed. 

In the case of malaria, we have more than 200 million cases annually, and we don’t have optimal tools. The SAGme believes that setting a date now, when there are so many uncertainties, may actually be counterproductive. Instead, the group is calling for an accelerated effort to achieve the already-approved targets of the GTS, a framework that includes 5-year targets for reductions in malaria cases and deaths through 2030. 

Following this alternative approach will actually take us along the path towards eradication. We can assess our progress at five-year intervals and eventually determine the tipping point -- when a time-limited, credible, achievable campaign to fully eradicate malaria could be launched. We are clearly not there yet.