The International

With the countdown towards the UN Millennium Development Goals’ (MDGs) 2015 deadline heating up, the release of the 2009 World Malaria Report is boosting confidence that halting the incidence of malaria and other major diseases by 2015 can be achieved. The report, released by the World Health Organization (WHO), concludes that increased funding for fighting malaria has had a profound effect in the coverage of malaria control interventions. A third of Africa’s most malaria-afflicted countries have now succeeded in reducing malaria infections by about 50 percent.

However, the report also emphasized that despite the increase in funding, there is still not enough money provided to fight malaria. In 2009, funding had increased to $1.7 billion, a significant rise from the $730 million available in 2006. However, this amount still falls short of the WHO’s funding goal of $5 billion per year, which the organization believes would ensure that the target will be met by 2015. The need to conduct more research on anti-malaria drugs is a major reason why the additional $3.3 billion in annual funding is needed, as the report outlines the malaria parasite’s growing ability to resist current drug treatments.

Malaria and its worldwide implications

Malaria is caused by a parasite called Plasmodium and transmitted to human beings through bites of infected mosquitoes. With early treatment, the duration of the disease can be shortened and complications arising from the disease can be prevented. However, if the disease remains untreated it can quickly become fatal by disrupting the blood supply to vital organs in the human system.

According to the WHO, about 3.3 billion people – which amount to nearly half of the world’s population – are at risk of malaria. In 2009, the WHO documented approximately 250 million malaria cases, and nearly one million deaths caused by the disease. Malaria is especially prevalent in developing countries in Africa, and particularly those located in sub-Saharan Africa. One in five childhood deaths in Africa are caused by malaria, and the WHO estimates that a child dies every 30 seconds from the disease in the continent.

Artemisinins and the malaria parasite’s growing resistance

While worldwide coverage of malaria control interventions is improving, there are still serious threats remaining that can damage this success, such as the Plasmodium parasite’s ability to generate resistance to drug treatments. According to WHO Director-General Magaret Chan, this stems from “the further spread of resistance to artemisinins, which has been identified in malaria parasites in Asia.”

Artemisinins are drugs used to treat some deadly strains of malaria. They have a 95% success rate in curing malaria if used in appropriate combinations with other drugs, in what are called artemisinin combination therapies (ACTs). Dr. Arata Kochi, director of the WHO’s malaria department, told BBC News: “If we lose ACTs, we’ll no longer have a cure for malaria, and it will be at least 10 years before a new one can be discovered.”

This is not the first time the Plasmodium parasite has demonstrated the ability to develop resistance to drugs. According to BBC News, in 1977 a drug called sulfadoxine-pyrimethanime was introduced in Thailand, where it had a nearly 100 percent success rate in curing malaria. But due to drug resistance, within five years it was curing only 10 percent of malaria cases, and has now lost effectiveness in almost every part of the world.

Professor Sanjeev Krishna, of the centre for infection at St. George’s University of London, believes that it is only a matter of time until the parasite becomes resistant to artemisinins. However, he also believes that the alarming child-mortality statistics related to malaria need attention, and that while resistance is weak and not widespread, ACTs should still be an option. He told BBC News: “The WHO should sit down with drug manufacturers to work out a strategy to ensure that the right drugs get to where they are needed, and at the best price.”

While drugs are a major method in fighting malaria, particularly when it comes to treating the disease, a major problem with them is the popularity of counterfeit drugs. Anti-malaria drugs are sold over the counter in countless places worldwide, and counterfeit drugs have become a popular way for drug dispensaries to make a greater profit. Mr. David Sintasath, an epidemiologist at the nonprofit Malaria Consortium in Bangkok, told the Associated Press (AP): “One of the problems is that there’s not really enforcement, so what happens when they find a drug that’s counterfeit or substandard? The policy is to take it away from them. That’s good until the next month when they get their next shipment, right?”

Ms. Chhien Rern, a 51-year-old Cambodian woman living with malaria, has bought malaria medicine from a shop in her village without a prescription. She told the AP: “After I took the drugs, I felt better for a while. Then I got sick again.” During her second bout of illness, the classic symptoms of malaria – headaches, chills, and fever – worsened. After being taken to the nearest hospital, doctors suspected that Ms. Rern had been sold counterfeit drugs.

A serious reason why counterfeit drugs are detrimental to the fight against malaria is that they can fuel the parasite’s resistance against ACTs. Dr. Delia Bethell, of the U.S. Armed Forces Research Institute of Medical Science, says: “The drug has been around for a long time and misused for a long time and this is all encouraging the parasite to develop resistance.” People can generate forms of drug resistant malaria when they take too little medicine, substandard medicine, or counterfeit medicine containing a hint of artemesinin. Often, counterfeit drugs are laced with artemisinin, prompting resistance. Moreover, once drug-resistant forms of malaria are established, they can be spread further through mosquitoes. Thus, one person’s usage of counterfeit medicine can lead to a widespread resistant disease.

Insecticide-treated bed nets

With resistance to anti-malaria drugs becoming an increasingly valid concern, a popular alternate method of fighting malaria has become insecticide-treated bed nets (ITNs). The 2009 World Malaria Report acknowledges the popularity of bed nets as being a preventative malaria method. The report also believes that ITNs have been a major contributor to the increase in malaria control coverage. According to the report, the number of ITNs produced worldwide jumped from 30 million in 2004 to 95 million in 2007. With increased resources, namely the increase in funding, there has been a rapid rise in the number of procured and distributed mosquito nets within countries.

Other international organizations are also promoting this malaria-fighting tool. The UN Children’s Fund (UNICEF) has increased its net-acquisition from 7 million in 2004 to nearly 20 million in 2007. The Global Fund to Fight AIDS, Tuberculosis and Malaria increased its distribution from 1.35 million in 2004 to 18 million in 2006. The data that is available for sub-Saharan African countries, the region where malaria is most prevalent, shows increases in ITN usage amongst children less than five years of age. 16 out of 20 of Africa’s most malaria-prevalent countries – including Gambia, Sao Tome & Principe, and Guinea-Bissau – have tripled their ITN coverage since 2000.

Because bed nets are less expensive than drugs, grassroots campaigns are also championing the cause. In 2006, the Nothing but Nets campaign was launched. It distributes bed nets throughout Africa for free with the aim of preventing malaria. The campaign works with the Measles Initiative – a partnership of the American Red Cross the US Centers for Disease Control and Prevention, the UN Foundation, the WHO, and UNICEF. In the first year of the campaign, almost 20 million bed nets were distributed in 10 African countries, such as Ethiopia, Kenya, and Nigeria. In 2009, working alongside the UN Refugees Agency, the campaign distributed nets to over one million refugees in Africa.

While bed net usage has its advantages, it has its drawbacks as well. ITNs are sometimes treated with DDT, a popular synthetic pesticide. Though DDT is one of the cheapest and most effective ways to reduce malaria, it has detrimental effects on wildlife and the environment. Thus, if the DDT used on bed nets is somehow transferred to crops, beneficial insects, or other wildlife, the result could be environmental suffering. Moreover, according a Chemical and Engineering News – a weekly magazine published by the American Chemical Society – new evidence indicates that prenatal exposure to DDT may retard child development and lead to preterm birth.

There are also social controversies that have arisen from the rise in international ITN campaigns. ITNs are a venture often financed and manufactured by Western companies and imported into African countries. Ms. Ceri Dingle, the director of the UK based charity WORLDwrite, which aims to develop and provide educational projects and programs that promote international understanding, believes that this can have negative effects on African development. She also believes that such vast international momentum behind the importance of non-African products to Africa can be derogatory. In her article called The great malarial bed-net swindle, she says: “One attraction of the bed-net campaign is that it circumvents national governments in Africa, which are presumed to be corrupt or insufficiently concerned about their people’s health and wellbeing. Western aid agencies can apparently be trusted with selling and shipping the nets and doing lots of monitoring because they are not up to their necks in corruption.”

Controlling the mosquito population

According to a study done by Imperial College London, scientists believe that intervening with the sex lives of mosquitoes can help combat malaria. The study was conducted on the A. gambaie mosquito, and concluded that these mosquitoes can only mate successfully if the male is able to seal his sperm inside the female using something similar to a plug. This plug is created by a coagulated mass of proteins and seminal fluids. Without the plug, fertilization cannot occur and females cannot reproduce. Because mosquitoes only mate once in their lifetime, the researchers conducting this study argue that disrupting their mating process can drastically reduce their numbers. The researchers stopped the plug from forming by eliminating a key enzyme that causes the seminal fluids to coagulate into the gelatinous solid mass.

The study’s lead researcher, Dr. Faminia Catteruccia, believes that with this discovery, scientists can develop new ways of controlling the world’s mosquito population, and limiting the spread of malaria by doing so. She spoke with BBC News on what methods scientists can use to eliminate the plug: “In the future we can develop an inhibitor that prevents the coagulating enzyme doing its job inside male A. gambiae mosquitoes in such a way that can be deployed easily in the field – for example in the form of a spray as it is done with insecticides – then we could effectively induce sterility in female mosquitoes in the wild. This could provide a new way of limiting the population of this species of mosquito, and could be one more weapon in the arsenal against malaria.”

Alternative treatment strategies

While preventative malaria methods like insecticide treated bed nets and controlling the mosquito population may be effective, they cannot be applied to cases where people already have malaria. Therefore, scientists have been searching for alternative anti-malaria drug solutions. In February 2009, a team of researchers at Monash University, in Australia, made a breakthrough in this search. They found a way to deactivate the final stage of the Plasmodium parasite’s digestive machinery, effectively starving the parasite of nutrients and disabling its survival mechanism. This process of starvation eventually led to the parasite’s death. Professor James Whisstock, the research team’s leader, said the results had laid the scientific groundwork to develop a specific class of drugs to treat malaria. According to Science Daily, an online publication that covers developments in scientific research, he said: “It is only early days but this discovery could one day provide treatment for some of those 2.5 billion people across the globe. Drug-resistant malaria is an ever increasing problem, meaning that there is an urgent requirement to develop new therapeutic strategies.”

Another promising development in malaria-treatment drugs came through experiments conducted by Japanese researchers in December 2009. In their experiment, a nasally administered malaria vaccine prevented parasite transmission from infected mice to mosquitoes, showing potential that it could do the same between infected humans and mosquitoes. Science Daily reported the researchers as saying: "To our knowledge, this is the first time that mucosal vaccination has been demonstrated to be efficacious for directly preventing parasite transmission from vaccinated animals to mosquitoes, and the results may provide important insight into rational design of nonparenteral vaccines for use against human malaria."

Financing the fight

According the 2009 World Malaria Report, valuable strides have been made in funding the fight against Malaria. Funds committed to malaria control from international sources have increased substantially, from approximately $0.3 billion in 2003 to $1.7 billion in 2009. The levels of domestic funding for malaria also appear to have been maintained over this period. In 2009, the three major sources of funds for malaria control programs were national government spending, external assistance from donors, and household or private expenditures. However, external assistance is what primarily contributed to the increase in funding.

Some countries with less external assistance have reported success in reducing the number of malaria cases, but these countries tend to be richer with better developed malaria programs, and likely receive more domestic resources for their programs. Thus, while high levels of funding may be responsible for decreases in malaria incidence, funding agencies tend to place funds in countries where success is more likely or has already been demonstrated. Countries that substantially reduce their malaria cases can face difficulties in justifying continued investment in malaria control. According to the WHO, continued or increased support is critical to protect current achievements and move towards the elimination of malaria.

Moving towards the elimination of malaria

For the United Nations and the WHO, the elimination of malaria is a definite future target. Throughout the duration of the Global Malaria Eradication Program, which existed up until 1987, 24 countries were certified as malaria-free. Since then, an additional 9 countries have reported intermittent periods of zero locally acquired cases. According to the WHO, because of the global momentum towards malaria intervention, some countries in subtropical and even tropical regions have been able to reduce their incidence of malaria to the extent that they consider to be close to its elimination.

While this movement is still in its early stages, the proven possibility of disease eradication provides hope. An example of an eliminated disease is smallpox. Smallpox was responsible for nearly 500 million deaths during the 20th century. In the early 1950s, about 150 years after the introduction of the smallpox vaccination, WHO figures showed that there were an estimated 50 million smallpox cases occurring annually worldwide. By 1967, these figures had fallen to around 10-15 million thanks to vaccinations. 1967 was the year the WHO launched an intensified program to eradicate smallpox worldwide. This global eradication campaign was successful, pushing back smallpox to northeast Africa, and finally to the last natural case in Somalia in 1977. The global eradication of smallpox was verified by scientists in December 1979, and endorsed by the World Health Assembly in 1980.

Because of the interest in pushing the boundaries of malaria-free areas around the world, the WHO, UNICEF, the UN Development Program, and the World Bank created the Global Malaria Action Plan (GMAP) in 2008. GMAP’s first target is that by 2015, at least eight to ten countries currently in the malaria elimination stage will achieve zero incidences of locally transmitted infections. By the end of 2009, these countries, which are currently in the elimination stage, included Algeria, Iraq, the Republic of Korea, and Saudi Arabia. GMAP’s second target concerns the years beyond 2015, where countries currently in the pre-elimination stage will move to elimination of the disease. Countries currently in the pre-elimination stage include Argentina, El Salvador, Paraguay, Iran, Malaysia, the Democratic People’s Republic of Korea, and Sri Lanka.