Royal Society Africa Prize Seminar 2017

The world has witnessed a golden decade in the fight against malaria. It all started with the ministerial conference on malaria in Amsterdam (1992) that brought back the focus to the rampant malaria problem. Political commitment grew, spearheaded by the African Heads of State and key donor countries. This eventually translated into new funding mechanisms such as the Global Fund, the Presidents Malaria Initiative or the UK’s program, and has resulted in a 20 fold increase in investment in the fight against malaria. Importantly it has allowed the scale up of tools and strategies, often the product of the R&D effort of the last decade of the 20th century. Insecticide treated bednets for vector control, rapid diagnostic tests (RDT) providing capacity to expand diagnosis to point of care and ACT for treatment constitute the core malaria interventions. The result has been a 40% decrease in malaria incidence rates and a 60% reduction in malaria attributable mortality. A truly unprecedented progress.

Armed with a new Global Technical Strategy endorsed by the World Health Assembly, that sets ambitious but achievable goals for 2030, we have a clear path to follow. However, the fight against malaria is now at a tipping point. Biological challenges continue to emerge and evolve: multi drug resistance threatening both our first line treatment drugs as well as those used for chemoprevention, insecticide resistance potentially impacting the effectiveness of vector control (our single most important tool during the last decade) and new parasites with HRP2 deletions that could render our mostly used RDT as ineffective. Financial investments in the fight against malaria has clearly plateaued over the last years and current funding is less than 50% of the estimated need. As a consequence, the rate of improvement in our fight against malaria has slowed down and could potentially start to reverse. Very significant coverage gaps to our core interventions remain, as nearly 45% of children under five in Africa are not protected by effective vector control and about 50% of malaria cases go undiagnosed and untreated. The result is that for a disease that is preventable and treatable, we still have in excess of 200 million cases and 400 thousand deaths.  Recognizing that we are at a tipping point, that new tools and smarter control will be needed and a renewed commitment to deploy the financial resources, especially from the affected countries themselves will be critical to achieve the goals of the GTS.

Malaria is still a major health problem, especially in sub-Saharan Africa. There has been substantial  progress in malaria control during the past 20 years, but the disease still kills nearly half a million people, mainly African children, each year.  In the part of Africa where I live and work, and in neighbouring countries, malaria is very seasonal and my research is directed at finding the best way of preventing  malaria when this occurs for only a few months each year. During the past 15 years, we have tested several new drugs and vaccines candidates against malaria and bacterial infections. Studies that have been particularly important, and which have had an influence on the management of malaria across the Sahelian and sub-Sahelian regions of Africa, are studies of Seasonal Malaria Chemoprevention (SMC), administration of antimalarials at monthly intervals to young children during the peak period of malaria transmission. These trials have demonstrated that SMC reduces clinical malaria by about 80% during the rainy season in the context of clinical trials. This intervention has now been rolled-out in Mali and many other countries in the Sahel region of Africa, saving many lives. Our current research investigates whether adding additional drugs, such as azithromycin and primaquine, or combining SMC with seasonal vaccination with the most advanced malaria vaccine (RTSS/AS01)  gives further benefits. Results on the  addition of low single dose of primaquine on the infectivity of mosquitoes and  on the addition of azithromycin to the antimalarial drugs used for SMC on  hospital admissions and deaths will be presented.

By 2014, Seasonal Malaria Chemoprevention (SMC) had only reached 4% of the eligible children. With funding from UNITAID, Malaria Consortium led a partnership which aimed to implement SMC at scale in multiple countries in the Sahel region, namely Burkina Faso, Chad, Guinea, Mali, Niger, Nigeria and The Gambia. Designed as a catalytic project to develop a sustainable market for SMC and to demonstrate feasibility, acceptability, safety, affordability and impact, the project provided SMC to 3.1 and 6.3 million children in 2015 and 2016 respectively. Preliminary data from costing studies indicate a weighted average cost of 4.2 USD per child reached per year in 2015, and 3.6 USD in 2016.