University of Pretoria: A UP Institute for Sustainable Malaria Control perspective on potential game changers to move the SADC region from malaria control to elimination

Malaria in the SADC region can be eliminated by 2030, but there are no quick fixes to achieve this. The complex disease is still responsible for almost half a million deaths annually across the globe, with more than 260 000 of those being African children under the age of five.

Malaria distribution in the Southern African Development Community (SADC) region is extremely heterogeneous, with five – Angola, Democratic Republic of Congo, Malawi, Mozambique and Tanzania – of the 29 highest malaria burdened countries (found in the SADC region) contributing to 51% of malaria cases globally. The World Health Organization (WHO) estimated that three-quarters of the population in the region is at risk of contracting malaria, including an estimated 35 million children under five years and approximately 8.5 million pregnant women.

In October 2021, the WHO approved the first malaria vaccine (RTS,S/AS01) for use among children living in moderate- to high-malaria transmission areas. Touted as ground-breaking, the vaccine brings hope to affected communities, but is not a cure for malaria. The vaccine has various limitations: it is only effective in very young children (five to 17 months of age); at least four doses, including a booster at 18 months after first dose, are needed for optimal effect; it prevents severe disease but not necessarily infection; and it is only effective against Plasmodium falciparum, which is the deadliest of the five parasite species that cause malaria in humans. These limitations highlight the need not only for further vaccine research, but also for continuous research and innovation to develop alternative interventions.

Adapting to a changing malaria landscape

Malaria control is challenging with a lot of variable factors, including environmental factors, having a negative impact on elimination targets. Current control strategies mostly focus on the vector (mosquito), which transmits the malaria-causing parasites to humans when feeding. Vector control includes indoor residual spraying (IRS) and/or insecticide-treated bed nets, but insecticide resistance is causing havoc on these interventions. Resistance, and changes in mosquito biting behaviour are slowing down gains made in malaria control over the past decade. Newly identified gaps and challenges are allowing for innovative alternative and complementary strategies to be developed through transdisciplinary research and collaboration. Some major gaps include the lack in human resources and leadership capacity.

In 2009, the SADC region renewed its malaria control efforts by establishing the Elimination 8 (E8) initiative: a coalition of eight countries working together across national borders to curb the spread of the disease. The E8, is pushing for zero cases and deaths within the next nine years. Significant variation in malaria transmission intensities exists across the countries. The four frontline countries – eSwatini, Botswana, Namibia, South Africa – are reporting very low transmission and are aiming for elimination by 2023. Low transmission does not allow the population to develop immunity against malaria, and the RTS,S vaccine would not be beneficial or cost-effective in these countries. The elimination target for the high-burden, second-line countries – Angola, Mozambique, Zambia, Zimbabwe – is set for 2030.

Capacity in malaria management and leadership

While malaria transmission has declined across the E8 countries, transmission dynamics remain highly interconnected, with the countries sharing related populations, economies, ecologies and epidemiologies. This interconnectedness highlights challenges, which identifies opportunities to be harnessed for more effective malaria control across the region. In addition, sub-optimal leadership and management skills within SADC national malaria control programmes (NMCPs) have been identified as problematic in the region. To address the lack in capacity, the Gates Foundation is financially supporting a course to be developed and delivered by the University of Pretoria Institute for Sustainable Malaria Control (UP ISMC) and stakeholders, to provide quality leadership development and management training to the NMCPs of the E8 countries.

The region has not benefitted from routine training, like that which is offered to NMCPs in West and East Africa. NMCPs will be capacitated with an appropriately skilled team of leaders, managers, implementation scientists, and facilitators capable of developing and applying effective evidence-based elimination strategies. The course will also enable the potential transition of women within these NMCPs into more senior positions.

Drug discovery and development

The countries face a high number of imported malaria cases due to cross-border movement of people from high-burden countries that are asymptomatic carriers (showing no symptoms or signs of malaria). Malaria treatment is dependent on antimalarial drugs that either prevent disease onset or treat infected patients and prevent death. The malaria parasite has multiple forms – the asexual replicative forms cause disease and transmissible forms (gametocytes) are taken up by mosquitoes to infect new hosts. The increasing parasite resistance against antimalarials is of great concern. Continuous discovery and development of innovative, new drugs that target all forms of the parasite, including gametocytes, are needed.

UP ISMC researchers and collaborating partners made a breakthrough discovery of two very potent chemical compounds that showed activity against all the parasite forms in the laboratory. Both compounds show potential as drug candidates for malaria treatment and transmission blocking. Blocking parasite transmission to the vector, regardless if people are asymptomatic, is important. Future antimalarial drugs capable of this feat can ultimately take the SADC region from malaria control to elimination.

Community involvement and participation

SADC Malaria Day, commemorated annually on 6 November, aims to raise awareness about malaria and to encourage communities to play their part to reach elimination. Community buy-in is needed for the successful implementation of control strategies run by their country’s NMCPs. The community needs to be aware of malaria research taking place to understand its purpose and benefits. People need to be empowered with knowledge about the disease for them to take responsibility for their own health. Malaria is preventable and treatable, but precautions must be taken to prevent contracting the disease and prompt treatment sought as soon as symptoms are noticed.

Malaria elimination in the SADC region by 2030 is possible by incorporating various innovative strategies along with existing control measures, and community participation.

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