Malaria eradication

The leaders of 18 Asia-Pacific nations at the 9th East Asia Summit (EAS) held in Myanmar's capital Naypyidaw, have committed to free the region of the mosquito-borne disease within the next 15 years. On Thursday, November 13, the regional leaders welcomed the proposal by the Australian and Vietnamese prime ministers, as co-chairs of the Asia Pacific Leaders Malaria Alliance (APLMA), to develop regional responses and address the issue of resistance to anti-malaria medicines in order to speed up efforts to eradicate the disease.

Australia and Vietnam were given the task to submit a plan for achieving this goal to the 10th EAS, set to be held in Malaysia. Although there has been a substantial reduction in the number of people falling ill and eventually dying from malaria, the World Health Organization (WHO) estimates that more than 630,000 people worldwide still die from the disease each year, most of them children under five years of age living in Africa.

The disease also remains a major cause of illness and death in the Asia-Pacific region, with an estimated 32 million new cases and around 47,000 deaths annually. Moreover, a study published in late July found that drug-resistant malaria parasites are spreading across Southeast Asia.

The study, carried out by the Mahidol-Oxford Tropical Medicine Research Unit, concluded that the strain of the disease that is resistant to the world's most effective antimalarial drug - Artemisinin - is now firmly established in border regions in four Southeast Asian countries - Thailand, Cambodia, Myanmar and Laos.

In a DW interview, Dr. Benjamin Rolfe, Executive Secretary of the Asia Pacific Leaders Alliance, and Patricia Moser, Lead Health Specialist at the Asian Development Bank (ADB) – which hosts APLMA – say that the recent pledge is not only a victory for health diplomacy, but it also prevents a potentially greater public health disaster given the increasing drug resistance of the disease in the Greater Mekong sub-region.

DW: How important is the political commitment to eradicate malaria?

Dr. Benjamin Rolfe and Patricia Moser: The commitment highlights substantial leadership from Australia, Vietnam and the region's heads of state, and represents a significant victory for health diplomacy. It also brings the region towards an endgame in a fight that has already been a success story for the health of people living in the area. Globally, we have seen a 50 percent reduction in malaria cases from 2000, averting an estimated 3.3 million deaths between 2001 and 2012 – mostly among young children.

Importantly, it also heads-off an even greater potential public health disaster: today’s frontline malaria drugs are becoming increasingly ineffective due to emerging drug resistance in the Greater Mekong sub-region, and likely soon throughout the Asia-Pacific region, and potentially even globally. If we don't stop this slow burning fire now, we risk losing the best tools and the overall fight, perhaps forever.

But the benefits of malaria elimination are not just a 'crisis averted.' It also means resources can ultimately be dedicated to other health services, productivity losses due to malaria can be minimized, and people’s out-of-pocket spending on health can be reduced. The absence of malaria will free up attention and resources for strengthened health systems across the region and better disease surveillance to manage other outbreaks, including ebola.

Why is malaria such a big problem in Asia?

The range of climates and natural environments in the region provide ideal habitats for specific species of mosquitoes, and also place people and communities at risk of exposure. The most persistent pockets of malaria are frequently found in remote rural and forested areas, where people tend to live and work in close contact with nature.

They are also home to some of the most socially marginalized and mobile communities, including those with poor access to health services and public information messages. Addressing malaria in these hard-to-reach areas and communities will be an essential part of malaria elimination.

In terms of malaria’s impact, two billion people in the region remain at risk of infection. The 30 million cases that occur in the region each year keep people away from work, exacerbate poverty, and the whole community suffers. Across the Asia-Pacific region, India (halved malaria cases since 2000), Indonesia (already went from 1.5 million cases per year to 500,000 in past decade), Myanmar, Pakistan and Papua New Guinea carry the highest malaria burden, accounting for over 80 percent of remaining disease in the region.

They have made good progress in the past decade, but there is a long way to go. Bangladesh, Sri Lanka, and Thailand have all reduced malaria by more than 75 percent since 2000.

Is the complete elimination of malaria in such a vast region really feasible?

In short: yes. Take the case of Sri Lanka as an example: after a turbulent history, the introduction of the chemical DDT in 1945 and near-elimination of malaria in the mid-1960s, the island experienced a deadly and dramatic resurgence of the disease, the number of cases shooting up to 1.5 million during 1967–1968 as a result of complacency and lack of funds. Major epidemics also occurred in the 1980s and early 1990s, but sustained financing has led to no cases for two years, despite 30 years of civil war. They have done it.

Several distinct approaches will need to be supported as part of the regional malaria elimination effort: for instance, we need to stop people getting infected with malaria using existing "vector control" methods, such as distribution and use of long-lasting insecticide-treated bed nets. There is also a good chance that during the next 15 years, a vaccine to prevent malaria will also be made available.

There is also the need to identify who really has malaria, given that the symptoms can be easily confused with other febrile illnesses. Moreover, sick people should be treated properly and with the best available medicines. This means that good quality drugs must be affordable and accessible to all people, including mobile, marginalized and border populations.

Last but not least, malaria programs and services can only be planned and delivered effectively if the local spread and impact of malaria is well understood. Surveillance, epidemiological investigation and reporting are critical to ensuring the response is targeted and appropriate for the local and national context. Of course, sustained and adequate financing of malaria programs is also essential.

What role does greater regional connectivity play in this context?

It almost sounds like a cliché to restate that communicable diseases do not respect borders, but it is as true for malaria as for any current challenge. Even if countries succeed in controlling malaria within their own borders, for example, the re-introduction of the disease from neighboring countries is still a constant worry. With many of the persistent pockets of malaria – including hotspots of drug resistance – occurring in remote border areas, there is only so much that one country can hope to do in isolation to control the disease, making inter-country cooperation imperative.

But arguably more importantly, one of the acknowledged prerequisites for effective malaria control – and ultimately, its elimination – is political commitment.

What would be the consequences of continuing the present course and not taking decisive action?

Continuing on the present course is quite unpredictable. The biggest potential game-changer is growing resistance to the drug Artemisinin, the mainstay of treatment for the most dangerous form of malaria. Signs of resistance were first reported in western Cambodia in 2006, and the problem has now also been identified in Laos, Myanmar, Thailand and Viet Nam.

Even though the numbers of malaria cases in these areas are relatively low, experts fear that if Artemisinin resistance was to take hold on the Indian subcontinent, the consequences could be incalculable. Although this has been seen before with previous antimalarial medicines, the window of opportunity to respond is relatively unchartered.

Another consequence of the current malaria response is that the current human and socioeconomic impacts of malaria would continue, albeit at incrementally reduced levels. The drain of 30 million annual malaria cases on regional health systems is huge, ranging from direct financial costs of diagnosis, care and treatment, to indirect consequences of health resources occupied with a preventable epidemic – not to mention the human, family and community effects of such extensive ill-health.

Can Asia’s battle against malaria inform other regions about what to do or not to do?

The region has shown impressive leadership in working towards and committing to this regional goal. It is the only region other than Europe to do so at such a leadership level. Malaria is a unique challenge because as the disease becomes better controlled, complacency can creep in: funds move away, laboratory technicians forget how to read slides, health workers forget to test for malaria when a patient presents with fever. An elimination goal is essential to focus thinking and resources until the job is completed.

What can tackling malaria tell us about how to fight other communicable disease such as ebola?

Large numbers of people living in poverty, in fragile settings with inadequate health systems and services is not only morally unacceptable, it is also a threat to global health security. Lack of access to quality preventative and curative care allows diseases to spread and become resistant to frontline medicines. Properly funded, stable communities and health systems are resilient to such threats.

Dr. Benjamin Rolfe is Executive Secretary of the Asia Pacific Leaders Alliance. Patricia Moser is Lead Health Specialist at the Manila-based Asian Development Bank.