Healthcare Getting It Right : Malaria

Malaria prevention and eradication is possible. Global health continues to lead the way.

1. The numbers should drive change. Between 2000 and 2015, malaria case numbers steadily decreased from 245 million to 230 million across the 108 countries that were malaria endemic in 2000. In 2021, there were 247 million malaria cases and 84 countries that were malaria endemic. We have less countries where malaria is endemic and we have more cases.

Lack of sustained progress should steer change. Partner organizations, philanthropic funders and others should require accountability
Four countries are responsible for half the cases and four countries are responsible for half the deaths [1]. Targeted plans for these 6 countries should be clear and projected risk for all 84 countries should be mapped. How the US distributes funds [2] in a way that matches burden or risk should also be clear.

2. Response should be time sensitive. Identified risks to malaria efforts [3] , such as ongoing pandemics, decline of insecticide treated bednet (ITN) effectiveness, parasite resistance and mutation and the urban-adaptation of mosquitos should be responded to promptly.

3. Key opportunities should be consistent. Opportunities for progress, highlighted in reports, could be consistent across organizations.

Goals for long-lasting and improved ITN products, as opposed to access to traditional ITNs, should be consistent in reports. Description of preferred ITN products are not found in every organization’s report.
New diagnostics and surveillance capacity goals should also be clear, especially given the discrepancy between resource dedication and report verbiage on this topic world health and US President’s Malaria Initiative (PMI) [1,4]. There is also discrepancy in the use of the “High Burden to High Impact” (HBHI) approach [1]
Research and development of new tools that can help accelerate global goals for malaria should be detailed. It is confusing to read that funding gaps for R&D [1] will place the world further behind on the eradication, because there is no tangible research highlighted. How will the world be further behind if we don’t know what we were banking on to be developed? How did science decide the particular tool or treatment is so sure? And, what are the projected funding needs for what projected time period for this assured solution? If it’s not a shot in the dark (and it sounds like this R&D isn’t) what was the specific funding ask and when would we expect the development to be complete?
Primary care and medical home model gameplans could be linked in the malaria reports [5]. Attention to urban areas could also be consistent across malaria organizations, not only in WHO reports on the issue[5].

4. Philanthropy should require improved preparedness from lessons learned.

If disruptions from the pandemic contributed to 63,000 malaria deaths and 13.4 million cases [1], what’s being done to address disruption prevention?

5. Antimicrobial resistance should be a collaborative priority. Gameplans should request global technology association, international pharmaceutical association and international regulatory collaborations. Antimicrobial resistance gameplans [6] for malaria should offer team metrics for world team evaluation.

Falsified and fake medication improvements should be measured.
Pharmaceutical regulatory and pharmaceutical decision-making improvements could be measured.

6. Vector response should be a collabortiave priority.

The global vector control response reports and attention to An. Stephensi are notable [7,8, 9]. How are international partners and how is international collaboration being measured?

7. Reports on intervention progress should be consistent, starting with denominators.

The WHO 2021 update on the global technical strategy identifies several measures for country and world progress [10]. The WHO 2021 update also states that measure denominators will shift from a country’s population to the number of people eligible for the intervention [10] . Neither the WHO 2022 [1] nor the US malaria reports [4,11] describe eligible people for the intervention in any progress measure. Why not?

8. Malaria vaccination needs a global gameplan.

A formal malaria vaccine initiative has been in place since 2021 [12]. There appears to be no cohesive, multi-agency strategic plan from the malaria-focused organizations [13,14,15,16,17,187,19]. Who will bring these groups together to maximize efficiency? What’s the worldwide gameplan?

United States involvement in malaria prevention, management and eradication is important. Improving response should also be important to the US.

1. PMI commitment to worldwide malaria response should continue to be championed. Continued interagency detail, such as how the US military operates within PMI, should be added [20]. Continued structure should be encouraged.

2. Malaria efforts outside of PMI should be summarized. US military, philanthropy and nonprofit malaria work outside of PMI could be accounted for. Even information as basic as how many cases were diagnosed or how many patients were treated would be important to know.

3. Evaluation of US management of malaria cases could be understood. Is there any room for improvement for management within the US [21]? This may include delayed diagnosis or diagnostic test issues, or this may showcase what malaria management gets right that other travel-related illness could mirror.

4. Training with international peers could be better described. Are there unfulfilled international requests for technical training beyond basic surveillance? If another country would like to mirror something specific, like hotline response, is there an easy and quick pathway for partnership?

5. Pharmaceutical and biotechnology leadership should continue. Are there ways to improve US pharmaceutical and diagnostic manufacturing international leadership to address the ongoing malaria crisis? Perhaps a culture and pulse check would help: are the annual 247 million malaria cases viewed as a crisis?

US military serviceperson concerns about adverse effects of antimalarial use should continue to receive response.

1. Evidence, research and literature synthesis should be transparent to the US population and the military population.

Literature synthesis that results in new recommendations should be acted upon immediately. The National Academies has been consulted for literature review and has made research recommendations. Potential neurological, psychiatric and eye effects warrant further study, and these areas should be targeted.
Literature synthesis that results in new recommendations should partner the recommendations with quality design.

Funding and scientific research could include improved biological and cellular models that compliment animal models.
Unpublished pharmaceutical data could also be requested.
High quality to the study design should be required.

2. Communication between the VA, MHS and public should improve. VA and MHS education on malaria and antimalarials is available [23]. Concerns and study summaries are not easily available. The analysis and dissemination of the National Academies information, at minimum, could be available. If we’re going to put in the attention and resources for professional third-party review, put in the attention to communicate the results.

3. Metrics should tell the story around service person concerns and malaria. Malaria case counts [25] are helpful. Neither estimates nor actual numbers of chemoprophylaxis adverse effects are available. Claims, denials, documented physician concerns or advocate hotline calls [24] should help tell the story. Compliance rates with chemoprophylaxis using anonymous and unbiased design should also tell the story.

4. Improved surveillance gameplans could be more strategic. If the side effects can last for years, and National Academies has concerns about study data only tracking 28 days after last pill is taken, what is the gameplan for improved surveillance? And how does this healthcare operations plan avoid the one-off studies or research study reliance on grant funds?

5. Literature synthesis should respect previous reports. In example, NASEM had an entire playbook on malaria vaccines and the US military published in 2006 [22]. When reviewing antimalarials in 2020, considerations to any other NASEM malaria reports could have been mentioned.

6. Literature synthesis should make space for anticipatory planning. In the case of malaria and the vaccine program omission from the NASEM antimalarial review, questions around improved vaccine surveillance and quality to independent, non-military malaria vaccine research could have been anticipated and addressed. In other words, what makes us believe that decades-long concerns around antimalarial effects will translate to vaccine uptake in a hesitant population? We should already be prepared for this population’s concerns and the link to the vaccine program should’ve been addressed.

The world does fantastic work in malaria prevention and management. Eradication is possible.

References

1. https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022

2. https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2022/04/PMI-16th-Annual-Report.pdf

3. https://www.who.int/news/item/08-12-2022-despite-continued-impact-of-covid-19--malaria-cases-and-deaths-remained-stable-in-2021

4. https://d1u4sg1s9ptc4z.cloudfront.net/uploads/2022/04/PMI-16th-Annual-Report.pdf

5. https://www.who.int/publications/i/item/9789240061781

6. https://www.who.int/news-room/events/detail/2022/11/18/default-calendar/webinar-launch-of-new-antimalarial-drug-resistance-strategy-for-africa

7. https://www.who.int/news/item/29-09-2022-who-launches-new-initiative-to-stop-the-spread-of-invasive-malaria-vector-in-africa

8. https://www.who.int/publications/i/item/WHO-UCN-GMP-2022.06

9. https://www.who.int/publications/i/item/9789241512978

10. https://www.who.int/publications/i/item/9789240031357