Stepping up fight against malaria in Asia to protect gains made everywhere

A mother from Myanmar and her child waiting to be seen at the Wang Pha clinic near Mae Sot, Thailand, near the Thai–Myanmar border. Her son has symptoms of malaria. Photo: Mark Tuschman 

This was originally published on Global Health TV on August. 31, 2018

The future of malaria in sub-Saharan Africa and everywhere else may depend on whether we can stop drug resistant malaria in five countries of the Greater Mekong subregion of Southeast Asia and whether new vaccines will work against it.

Great progress has been made against malaria on both continents. The incidence rate of malaria has decreased 18% globally between 2010 and 2016, according to the World Health Organization. The WHO South-East Region recorded the largest decline (48%) followed by the African Region (20%). Malaria cases worldwide have fallen from 237 million in 2010 to 216 million in 2016.

Two years ago, Sri Lanka became the first country in the region to eradicate malaria. Six more countries (Bhutan, China, Malaysia, Nepal, South Korea, and Timor-Leste) are on track to eradicate it by 2020 and the other 15 nations are targeting 2030. But a few of those 15 countries are struggling – malaria cases increased in six of them in 2016. India has the third largest burden of malaria in the world, accounting for 89% of malaria cases in the Southeast Asia Region.

“We’ve made extraordinary progress in the Asia-Pacific Region,” says Dr. Ben Rolfe, CEO of the Asia Pacific Leaders Malaria Alliance based in Singapore. “Malaria has been halved, and then halved again. Even Myanmar has made extraordinary progress in the most difficult of circumstances. The downside is that we have only bitten off the easy fruit. We are now getting down to dealing with remote communities with very little access to health services. It gets exponentially harder to reach those places.”

And to make matters worse, drug resistant malaria was first reported in 2008 in Cambodia and has since spread to four other countries of the Greater Mekong subregion – Laos, Myanmar, Thailand and Vietnam. If this resistant strain spreads to Africa and India, it could wipe out the gains of the last 20 years. This photo essay shows images from a malaria research site on the Thai-Myanmar border.

The only wait to safeguard those gains is to wipe out malaria in the Greater Mekong subregion and the larger region. To that end, global donors led by the Australian government, have made financial commitments to fight malaria in Asia. Domestic financing for malaria has increased by over 40% in the Asia-Pacific between 2015-2017 as compared to 2012-2014 (Nepal, Thailand, Myanmar, Vietnam and Timor-Leste all increased domestic financing by more than 100%). The Global Fund to Fight AIDS, Tuberculosis and Malaria have come up with $243 million. And the Australian government announced an AUD $300 million package to support efforts to end the disease in the Asia-Pacific region.

The private sector is also playing their role in the region.

Last month the pharmaceutical company GSK and the Medicines for Malaria Venture (MMV) announced that Tafenonqine, a new drug specifically for the recurring  (or relapsing) form of malaria (which accounts for a half of the Asia-Pacific’s malaria burden) has been approved by the U.S. Food and Drug Administration. Rolfe says Tafenonquine will be “a real game changer in this region particularly when you’ve got the parasite hiding in people’s livers.”

Novartis, another pharma company, is now testing two drugs – known as KAF156 and KAE609 – specifically against drug-resistant malaria in Africa, Thailand and Vietnam. If they prove effective, they would be a huge step forward in making malaria treatment simpler and safer.

“We are very excited about those two antimalarials because they are distinctly different from current antimalarial therapies available and have the ability to combat the resistance that we now see emerging in the Mekong sub-region, specifically in Cambodia,” says Dr. Lutz Hegemann, global development head, Established Medicines and Anti-Infectives at Novartis. “Those two molecules are not only distinct from what is out there, but they are also distinct from each other. They are potentially useful beyond just the treatment of uncomplicated malaria.” This means that they could potentially help prevent malaria, as well as treating it.”

Both drugs are in clinical phase 2 (which is followed by Phase 3 and then FDA review). Lutz estimates that, if development goes quickly, he would expect to see them on the market in 5+ years. So far, he says, the data is very encouraging.

Lutz said that Novartis is deeply committed to moving forward with KAF156 and KAE609 and has invested $100 million in those two compounds plus related activities to help bring those products to market in close partnership with MMV.

Rolfe frames the malaria fight as an extraordinary mission. “It’s not like global warming that has no clear end date,” he says. “We are making huge traction. Look at the Philippines and Sri Lanka. There are some incredibly dedicated people working quietly every day. People who would normally be wearing suits are out in Land Rovers and small boats with their sleeves rolled up making sure they finish the job. That kind of commitment is an extraordinary thing to be a small part of.” 

But Rolfe said we have to defeat malaria in the Greater Mekong sub-region to safeguard those gains. “Donors have invested billions of public money in making historic gains fighting malaria in sub-Saharan Africa. If ACT (artemisinin-based combination therapy) resistant malaria spreads to Africa, just as resistance to chloroquine, just as resistance to sulfadoxine-pyrimethamine did, we’re going to see what we saw the last time – a massive increase in child mortality solely due to malaria.”

Australia has stepped up its regional leadership in the malaria fight, announcing an AUD $300 million, five-year package called the Health Security Initiative for the Indo-Pacific, a five-year program focusing on the avoidance and containment of infectious diseases. Since launching in October 2017, the initiative has committed AUD $68.5 million for malaria activities.

 “I can assure you that Australia is deeply committed to this goal of the elimination of malaria but the key is to work in partnership,” Australian Foreign Minister Julie Bishop, who resigned last week, told the Malaria World Congress in Melbourne in July. “No one country, no one agency, no one foundation can do it alone.” As we have seen with polio eradication, we can eliminate malaria in our lifetime. We know that some countries will achieve it by 2020, others later, but if we work collectively and collaboratively this goal is within our grasp.”

If you want to take a deeper dive into drug resistant malaria in southeast Asia, check out Amy Maxmen’s excellent article in the July 26th issue of Nature.