Failing Drugs and Super Bugs: The Race to Eliminate Malaria

08 February 2017 by Izaskun Gaviria, Senior Fund Portfolio Manager – RAI, The Global Fund to Fight AIDS, Tuberculosis and Malaria

Recent news stories have painted a dire picture of efforts to combat malaria – from drug-proof cases seen in the UK to the rise of especially fit multidrug-resistant parasites in the Mekong.

But malaria experts say that’s not the full picture. Yes, drug and insecticide resistance is a serious problem. Yet we are closer to malaria elimination in more countries than ever before.

The fight against malaria is one of the biggest success stories of the 21st century. The number of deaths caused by malaria globally declined 48 percent between 2000 and 2015 – that translates to an estimated 6.4 million deaths averted. The World Health Organization declared Sri Lanka malaria-free in September 2016 – one of only a handful of tropical countries to achieve the milestone. The Global Technical Strategy calls for the elimination of malaria in at least 10 countries by 2020.

So if malaria cases and deaths are on the decline worldwide, why are super bugs making headlines?

A newly published study has prompted some of the coverage, and I have been joined by one of the authors, Dr. Arjen Dondorp, at a meeting in Cambodia this week of the Regional Artemisinin Initiative steering committee. RAI is a collaboration of funders, multilateral agencies, technical partners, scientific researchers, communities and governments supported by the Global Fund to pursue the goal of malaria elimination in five countries of the Greater Mekong: Myanmar, Thailand, Cambodia, Laos and Viet Nam.

Dr. Dondorp, Professor of Tropical Medicine in Oxford and Deputy Director of the Mahidol Oxford Clinical Research Unit in Thailand, chairs the RAI steering committee. He says despite a general downward trend for malaria, antimalarial drug resistance is getting worse quickly, now with resistance to both artemisinin and the partner drug component, and fitter malaria strains spreading over wide geographical areas. As countries whittle down the areas and populations affected by malaria, only the strongest parasites can hold out. Failing to eliminate malaria quickly could allow these difficult-to-treat, resistant strains to cause a resurgence.

Unwittingly, humans have helped the parasite develop resistance. A combination of drugs – artemisinin and piperaquine – when taken correctly are effective at curing malaria. However, in some places, people never make it to clinics for diagnosis and treatment, or take artemisinin on its own, incomplete courses or substandard quality drugs, all of which drive drug resistance. 

These are precisely the kinds of obstacles to elimination the Global Fund partnership is working to address through RAI. Together, we are working to close gaps in supply chains, so the right drugs are in the right places at the right time. A network of local organizations works to reach highly mobile and remote populations, such as rubber plantation workers, and ethnic minorities who historically have been underserved by health systems. Improved surveillance data means that when an outbreak flairs up, an appropriate response can be deployed.

The regional implementation of these strategies is key, according to Dr. Pascal Ringwald, Coordinator, Drug Resistance and Containment, WHO Global Malaria Programme – also a member of the RAI steering committee. “A containment approach tries to build a firewall around a cluster of related drug-resistant cases,” he says. “But that is not the case in the Mekong, as several distinct drug resistant groups are occurring at the same time. That is why we are focused on elimination, which requires this regional coordination and cooperation.

“We are really well engaged to win the race,” Dr. Ringwald says. “But we do need to act extremely urgently. This is the moment. We have all the tools to be successful.”

Dr. Dondorp concurs. “We are not losing the race toward elimination, but we are at a crossroads. Malaria has never been so low, but the resistance problem is worsening. So the window of opportunity is limited. We have to make a big strike now.”

The Global Fund partnership will invest more than US$242 million in five countries through RAI over the next three years to help make that “big strike.”