Written By Ken Walker of InChrist Communications

10 minute read • April 20, 2021

It’s a back-and-forth battle growing tougher in the face of COVID-19, with mosquitoes responsible for spreading the disease taking on the appearance of brass-helmeted warriors immune to nearly every device aimed in their direction. Malaria, humanity’s most deadly infectious disease, is making a comeback while our primary defense—net distribution—is being handicapped by the disruptions to normal life caused by the worldwide pandemic.

Insecticidal Nets a Mainstay, but Declining to Protect in Some Cases

Niger: Demilla and her children now sleep under the safety of a bed net, which protects them from malaria-carrying mosquitoes, which have regularly affected many of her close family members, including her two children. Photo by Nothing But Nets, Instagram

That news appeared last summer in Nature Communications, which published research showing insecticide-treated mosquito nets—considered a mainstay in combating malaria—are not providing the protection they once did.³¹

According to another report in ScienceDaily, scientists say that’s cause for concern in tropical and subtropical countries. Long-Lasting Insecticidal Nets (LLINs) were credited with saving 6.8 million lives over a recent 15-year period.³²

Dr. Stephen Carl, a malaria researcher in Australia, said LLINs add a community-level protective effect by significantly decreasing the mosquito population, which benefits even people not using nets. In Papua New Guinea, their introduction in 2006 led to a significant decline in cases, but between 2013–14 and 2016–17, the rate of infections rebounded from less than 1 percent to 7.1 percent.³³

“[LLINs] are the only tools used at present in the national campaign against the mosquitoes that can carry malaria,” said study co-author Dr. Moses Laman.

“Malaria kills around half a million people worldwide
each year, so any suggestion that the nets are not working
is cause for grave concern.”³⁴

While conclusions are still being formed on the news reported in Nature Communications, it appears diminished bioefficacy at the manufacturing level may be contributing to the problem of resurgence in malaria incidents.

Mosquito bites will result in more than 700,000 malaria deaths around the world this coming year — wiping out the equivalent of the entire population of Washington, D.C., says a recent report by GFA World. The report — Winning the Ancient Conflict Between Man and Mosquito — coincided with World Mosquito Day, Aug. 20, 2020.

Debating Treated Nets vs Untreated Nets

But not everyone agrees that treated nets are necessary. Research published just prior to the ScienceDaily report questioned if their cost makes the fight harder. One report in Malaria Journal said although more than 90 percent of the burden occurs in Africa, most prequalified nets approved by the World Health Organization (WHO) are manufactured elsewhere. The publication said many local manufacturers lack the capacity to produce insecticidal nets at a competitive scale and pricing.³⁵

Fredros Okumu is a Kenyan parasitologist and entomologist, who developed a synthetic mosquito lure which was 3-5 times more potent than natural human odor.
Photo by Fredros Okumu, Twitter

By relaxing conditions, it is conceivable that non-insecticidal but durable—and possibly biodegradable—nets could be readily manufactured locally, wrote author Fredros Okumu. While not aiming to discredit treated nets, he said he wanted to illustrate how a singular focus on insecticides can hinder innovation and sustainability.³⁶

“The public health value of nets is increasingly driven by bite prevention, and decreasingly by lethality to mosquitoes,” Okumu said. “For context-appropriate solutions, it is necessary to acknowledge and evaluate the potential and cost-effectiveness of durable untreated nets across different settings.”

In his lengthy report, he also observed that developers should, instead of overemphasizing the need for new insecticides, ensure that bed nets are accessible, durable and properly used, even if non-insecticidal.

“New insecticides can then be developed for other forms of vector control,” Okumu said. “It has been demonstrated that resistant mosquitoes can survive up to 1,000-times the concentration of insecticides that kill susceptible populations. Such strongly resistant mosquitoes may naturally incur major survival and fitness costs in nature but are unlikely to be killed directly by insecticidal nets.”³⁷

Malaria caused by mosquitos is one of the main killers in West Bengal, India, as the villages in these areas are surrounded by tea plantations and forests with lots of insects. On World Mosquito Day, August 17th, 2016 the local Believers Eastern Church distributed over eight hundred mosquito nets to villagers from economically poor backgrounds, who would be unable to afford to purchase their own.

Fighting a Coronavirus that Hampers Bed Net Distribution

However one looks at the necessity of treated nets, distribution of any nets—treated or untreated—has been a cause for concern during the coronavirus outbreak.

Writing in Nature Medicine, researchers forecast the possibility of 779,000 deaths in sub-Saharan Africa over a 12-month period, culminating in the summer of 2021.³⁸ That compares to a WHO worst-case estimate of 769,000 malaria deaths this year, a mortality rate not seen in two decades.³⁹

In the face of COVID-19, Okefu Oyale Okoko, deputy director of the National Malaria Elimination Programme in Nigeria, said it would still be important to ensure continuing deployment of vector control interventions to not only sustain gains in malaria elimination, but ensure against its resurgence.

According to a report in The (London) Telegraph, researchers concluded that treating children with fever as if they have malaria, even if not diagnosed with the disease, could save nearly 200,000 lives. And, of course, prompt distribution of bed nets could prevent hundreds of thousands of deaths.

When final statistics are available, researchers from the Imperial College of London predict if control programs were halted due to COVID-19, the number of cases during 2020 could double compared to 2019. In Nigeria alone, they said cutting treatment and delaying the distribution of bed nets could result in 81,000 additional deaths.

James Whiting, Chief Executive at Malaria No More UK, whose goal is to end deaths and suffering from malaria. Since 2000 deaths of the biggest killer disease in human history have been reduced by 60%, saving 7 million lives. But in the last few years malaria has started to rise again per WHO World Malaria Reports. Photo by Hope and Homes for Children

Typically distributed at community meetings, such gatherings to distribute bed nets faced interruptions over the last year because of event cancellations or poor attendance because of coronavirus fears.

Telegraph correspondent Anne Gulland wrote that researchers’ modeling found that provision of bed nets is critical since those treated with long-lasting insecticide have effects that continue for three years. More than half of the 47 countries most badly affected by the disease were due bed net distributions in 2020, with 228 million nets due to be handed out. That would have been the largest number ever.

James Whiting, executive director of Malaria No More UK, told the newspaper: “This important modelling is a reminder that efforts to end malaria sit on a knife edge. Protecting people against COVID-19 cannot be pursued in isolation. Governments must see maintaining efforts against malaria as a core part of pandemic preparedness or risk a catastrophic domino effect.”⁴⁰

Soon after the Telegraph article, computer magnate turned philanthropist Bill Gates echoed the necessity of not allowing the pandemic to distract attention from the fight against mosquito-borne disease. The pesky insects are out infecting millions with a disease that kills a child every other minute daily, he wrote in his online blog.⁴¹

In his lengthy report, [Okumu] observed that developers should, instead of overemphasizing the need for new insecticides,
ensure that bed nets are accessible, durable and properly used,
even if non-insecticidal.

Gates—head of the Gates Foundation, a key non-governmental organization fighting malaria’s spread—said lockdowns and other regulations made it difficult for health workers to provide prevention and treatment across Africa. He said there were also interruptions to supplies of essential malaria tools like bed nets and anti-malaria medicines. Instrumental in reducing malaria deaths by more than half since 2000, he said interruption of these services could mean mortality levels not seen since the turn of the century.

“There is not a choice between saving lives from COVID-19 versus saving lives from malaria,” Gates wrote. “The world must enable these countries to do both. Health officials urgently need to step up to the challenge of controlling the pandemic while also making sure that malaria, as well as other diseases like HIV and tuberculosis, are not neglected.”⁴²

Progress Ebbs and Flows in the Fight to Beat Malaria

These recent developments place a heightened spotlight on World Malaria Day, observed on April 25. Fortunately, despite the high death toll and other troublesome signs lately, not all the news about malaria treatment is bad. There are gains amid the setbacks.

This woman in West Bengal was very grateful to Believers Eastern Church and its leaders for providing her with a mosquito net to protect herself and her family from vector borne diseases like malaria.

One positive example is Myanmar, where the annual malaria death toll of 3,800 a decade ago has decreased to approximately 170. The Global Fund to Fight AIDS, Tuberculosis and Malaria credits the efforts of 17,000 community volunteers who provide rapid testing and treatment, with serious cases referred to health facilities. Volunteers also educate the public through national antimalaria campaigns.⁴⁴ Unfortunately, it's unknown if the recent military coup in Myanmar will adversely impact the progress it’s achieved in the prevention of malaria.

News of another positive development appeared last October in Legion. About the same time the United States revealed a COVID-19 vaccine would be ready by the end of 2020, the Canadian magazine reported that a noted medical journal announced a new approach to fighting malaria.

Mosquito Spit Draws Attention to Potential Malaria Vaccine

Legion reported a clinical researcher for the U.S. National Institute of Allergy and Infectious Diseases has developed a vaccine for mosquito-borne diseases, based on mosquito spit. It causes the immune system to recognize mosquito saliva proteins and produce antibodies. The antibodies promote immunity by binding to pathogens to prevent them from damaging cells, plus coating pathogens and alerting other immune cells to attack and remove them.

“Those antibodies recognize the proteins the next time they’re encountered, sparking an immune response that goes into action to impair or prevent infection—and not just to malaria, it turns out,” wrote author Sharon Adams. “In animal studies, saliva vaccines impaired development of mosquito-borne Zika virus and sandfly-borne leishmaniasis.”⁴⁵

In the first human trial of this vaccine in 2017, Adams said a strong immune response was observed among 49 volunteers, with only minor side effects. Next it will be tested on larger groups; if clinical trials continue to prove successful, the first effective malaria vaccine may be just around the corner.

Maya from a village in Uttar Pradesh was given a mosquito net as a Christmas gift by GFA World. She can now protect her family from mosquito bites that transmit vector-borne diseases like malaria, Zika, dengue, encephalitis and more.

In addition to this promising development, a European magazine carried a report from a healthcare company official saying there are antimalaria positives to be gained from the COVID-19 fight. Hogan Bassey, a Nigerian native who experienced several bouts with malaria as a child, noted that the pandemic highlighted system failings in global healthcare. He said if we are able to address those problems, the world will be better positioned to eradicate malaria and other diseases.

The chief innovation officer and founder of LivFul said his company is working with others—including nonprofits—to develop a repellent that it hopes will prove an efficient control tool. It has been working on a project in Ghana with a pharmaceutical company to improve one of the repellant’s ingredients, using LivFul’s technology to drive access.

After moving to the USA from Nigeria, Hogan Bassey began to work on an insect repellent formula to change the world. The true breakthrough for his new company, LivFul, came after partnering with a physical chemist to create a brand-new technology which allows insect repellent to remain on top of the applicant’s skin for 14 hours at a time. Photo by Terry News

“When we developed a revolutionary family-friendly insect repellent to halt the transmission of diseases like malaria and Dengue fever, we knew we could have a significant impact on insect-borne disease,” Bassey wrote in EPM Magazine. “If people in malaria-prone areas can purchase and use our repellent, these diseases can be stopped before they destroy lives, families, communities and industries.”⁴⁶

Such a product won’t be the first tool developed. National Geographic recently reported hundreds of thousands of children across Kenya, Malawai and Ghana have been receiving the RTS,S vaccine, whose development has taken 35 years and cost hundreds of millions of dollars. While some African health professionals have asked if the expense and logistics of multiple vaccinations are worth it, the magazine said some Chinese scientists have been utilizing a new approach: preventing malaria from even occurring.

It goes back to 1972, when the Chinese discovered Artemisinin, a drug used to treat malaria. Now, scientists there believe Artemisinin Combination Therapies (ACTs) can be delivered to an entire community simultaneously, through Mass Drug Administrations. The goal is to reduce levels of the malaria parasite in human blood, so mosquitoes won’t contract it and spread it.

“The life cycle for a mosquito is 30 days,” explains Ethan Peng, senior manager in Kenya for the Chinese company New South, which manufactures ACTs. “So by mass medication, we can clear the source from all human beings (so) the mosquitoes cannot pick up on the malaria parasite again with their short lifespan.”⁴⁷

People in rural villages in West Bengal often suffer from malaria, but these folk were very happy to receive mosquito nets for their families. Over eight hundred mosquito nets were gifted to the villagers who come from economically poor backgrounds, and might not have been able to afford to buy them on their own.

Mosquito Nets Still the Leading Tool for Protection

Vandana and Vaibhav are sleeping peacefully on their bed in Maharashtra under their mosquito net which protects them from mosquito bites. They received their bed nets from a Christmas gift distribution from GFA World.

When it comes to fighting malaria, the bed net still appears to be the leading tool. When COVID-19 hit in March 2020, WHO malaria scientist Pedro Alonso expected the biggest malaria disaster in 20 years after African countries temporarily suspended bed net campaigns.

That didn’t seem to be happening, the scientist said five months later. He credited lobbying by WHO’s Global Malaria Programme and its partners, which persuaded countries to resume their net distribution campaigns. Despite concerns over continuing COVID-19 problems, Alonso said, “We probably stopped the first big blow.”⁴⁸

Among the many non-governmental organizations doing their part to distribute mosquito nets is GFA World (GFA).

The difference net distributions make can be seen in the stories of people like Baharupa, a 55-year-old farmer and father of three who felt pressured to drink alcohol at many village-wide events. Not only did he often wind up drunk, he developed an addiction. That all changed after Satyam, a GFA worker, organized a distribution of 4,000 nets.

After 71 years, Bhranti, a widow, no longer has to worry about mosquitoes biting her in the night thanks to the new bed net she received from a distribution event.

“Who can give us mosquito nets without money?” Baharupa wondered. “This shows [the believers’] love towards us.”⁴⁹

This experience so touched Baharupa that it began a transformation in his life.

Another story of relief involves a 71-year-old widow whose husband had died more than a decade prior. With four daughters all married, Bhranti spent evenings alone, worried about the tattered net providing her only protection from mosquitoes. She received a new net through a distribution organized by a GFA worker.

“I am so grateful to the [GFA workers] for their love and care and for providing a mosquito net,” Bhranti says. “Now I do not need to worry about buying a mosquito net as I have been provided a new one.”⁵⁰

Even amid the problems COVID-19 has caused in poorer parts of the world, GFA’s supporters have been able to help local workers in the field save lives and prevent more tragedies during the pandemic, says GFA’s founder, Dr. K.P. Yohannan.

Written By Ken Walker of InChrist Communications

10 minute read • April 22, 2020

Because the deaths came in ones and twos, the mid-summer and early fall 2019 headlines were more local than national in scope. They told of a 70-year-old man in Massachusetts—one of 10 people infected in the state—dying from Eastern equine encephalitis (EEE)s, a virus transmitted through a mosquito bite; two deaths in Connecticut, where officials identified EEE-carrying mosquitoes in a dozen municipalities; and a 68-year-old man in Ohio who died from mosquito-linked West Nile virus.

It is critical that patients everywhere have access to the regimens needed to combat this “deadly scourge.”
Photo by Nothing but Nets

Before the year ended, more than a dozen fatalities had been recorded. As of mid-November, the Centers for Disease Control reported three dozen cases of EEE in 2019, the highest in 60 years.¹ The annual average for the previous decade: just seven.

Granted, a relative handful of tragic fatalities from EEE doesn’t compare to thousands of deaths attributed each year to malaria, which still vexes health officials centuries after its discovery. Still, this five-fold increase in EEE cases may help sensitize Americans to the scourge of mosquito-borne health dangers. Such an awakening is especially timely with the observance of World Malaria Day on April 25, which draws attention to the 400,000 lives per year lost to this deadly disease.

In fact, while the total number of confirmed COVID-19 cases worldwide (on the date of this report) currently stands at 2.5 million and rising, each year there are more than 200 million reported cases of malaria, mostly in sub-Saharan Africa and South Asia.

A previous special report on this topic, entitled “Fighting Malaria – A Chilling Disease,” details how mosquito netting and malaria prevention are being used to combat this parasitic genius. This update unfolds the ongoing efforts of the global community to combat mosquito-borne scourges, including malaria, even among developing nations.

Intermediate magnification micrograph of maternal malaria. Placenta. H&E stain.
Photo by Nephron, Wikimedia (CC BY-SA 3.0)

Advancements in the Fight

Thanks to a consortium of governments, foundations and non-governmental organizations, there have been advancements in treatment. In 2015 the WHO announced the global incidence of malaria had finally slowed: Between 2000 and 2015, mortality rates in Africa fell by 66 percent overall and 71 percent among children under 5, the most vulnerable victims.³

“The last decade has seen a significant transition in the ways that countries are responding to malaria,” Dr. David Reddy, CEO of the partnership, Medicines for Malaria Venture, said in a 2015 interview. “Significant new international resources (including Global Fund and President’s Malaria Initiative) have been better mobilized in the last 10–15 years to support programmatic strengthening and introduce greatly improved tools to prevent and treat malaria.”⁴

In his foreword to the WHO’s 2019 report, Director-General Dr. Tedros Adhanom Ghebreysus noted that at least 10 countries are on track to reach the 2020 elimination milestone set in its long-term global strategy. In 2015, he said all those countries were malaria endemic, but now have either achieved zero indigenous cases or are nearing that goal.

In 2018, 259 million Rapid Diagnostic Tests for malaria were distributed by National Malaria Programs across the globe. Here Souleman Balde, a 32 year-old-community health worker, tests a child for malaria in a village in the Bafata region of eastern #GuineaBissau.
Photo by @UNDP Guinea Bissau / Gwenn Dubourthoumieu

More resources are appearing too. Just before the release of the WHO report, the board of the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria approved increased funding for investments over a three-year period (starting in 2020) to fight these epidemics. The investments total more than $12.9 billion U.S. as of March 2020.

Medical advances are occurring as well. In September of 2019, a paper in Science Translation Medicine described how redesigning molecules first designed to treat a skin disease (psoriasis) could lead to an effective new drug. An international team of researchers described modifying a class of molecules called pantothenamides to increase their stability in humans. In brief, the new compounds stop the malaria parasite from replicating in infected people and are effective against parasites resistant to current drugs.⁵

One of the paper’s authors, Penn State University professor Manuel Llinás, said while pantothenamides are potent against parasites, they become unstable within biological fluids because an enzyme clips them apart before they can act. Changing a chemical bond prevents this from happening.

Significant new international resources ... in the last 10–15 years ... introduce greatly improved tools to prevent and treat malaria

“By also preventing the transmission of malaria parasites from infected people into mosquitoes, these pantothenamides can reduce the chances that mosquitoes will be infectious to others,” Llinás said. “It is currently widely accepted that next-generation antimalarial drugs must target the parasite at multiple stages to both cure the disease in an infected individual and prevent its spread to others.”

This news came on the heels of a story by Joshua Carroll in The Guardian newspaper about Myanmar becoming an example in the fight against malaria. It chronicled how thousands of volunteers received training and supplies from donors after political reforms opened the door for a flood of aid.

These efforts helped save thousands of lives and turned Myanmar into a leader in the battle to eliminate the disease. Nationwide in 2010 nearly 4,000 people died from malaria, but in 2017 that number dropped to 200.

“Dr. Patricia Graves, a leading specialist on the transmission and control of malaria, is confident Myanmar is on track to be malaria-free by 2030,” Carroll wrote. “The country’s success with village-based health workers ‘is a huge thing that other countries can learn from,’ she says.”⁶

A study of Africa released in the spring of 2019 found that the single-most important factor to a 15-year decline in malaria fatalities was increased distribution of insecticide-treated bed nets. Photo by Nothing But Nets

Rising to the Challenge

Drs. Nana Minkah (back) and Deba Goswami work with Kappe Lab colleagues to develop a vaccine for malaria. Photo by Seattle Children’s Hospital

One of the ironies in the fight against malaria is that past victims are combating it, including people like Dr. Nana Minkah, a scientist at the Kappa Lab at Seattle Children’s Hospital. Growing up in the sub-Saharan nation of Ghana, he contracted the disease multiple times. Among his memories are bouts when he spent more than a week in bed with pain and chills so bad he visibly shivered.

In 2015, after earning a Ph.D. in molecular genetics and biology, Dr. Minkah joined the Kappa Lab. Even though he didn’t have experience in parasitology, he wanted to work on malaria, especially since it still plagues his homeland.

One of the ways the lab hopes to pioneer new methods of preventing malaria is with genetically engineered vaccines. In March of 2019, it successfully completed a vaccine with a first-generation strain of the most lethal parasite. Such vaccines rely on a basic principle: to give the immune system an advantage over a pathogen by teaching it to recognize the invader before the infection occurs.

“I wanted to do work that has clinical implications with the potential to save the lives of people who look like me,” Dr. Minkah said. “What we are trying to do is a tall order. We are trying to develop a product that will create unnatural immunity.”⁷

Despite such inspiring stories, challenges still exist. For example, while malaria was eliminated in the U.S. in 1951, the country still has Anopheles mosquitoes that can bite an infected person and transmit to others.

Health workers take a blood sample from an infant to test for malaria at a clinic along the border between Thailand and Myanmar. Photo by Ben De La Cruz / NPR

During last summer’s EEE outbreak, health officials in five southwest Michigan counties warned of a “critical risk” of the virus in 35 communities, with another 40 at high risk. Dr. Brian Chow, a doctor of infectious diseases at Tufts Medical Center, said 2019 seemed to be much more severe than in years past. “It is a concern,” Chow said.⁸

Such situations point to the vigilance needed for the fight. A 2019 article in the Scientific American pointed out how, over time, drug treatment of the disease lose their effectiveness as parasites grow resistant to it. For example, in the 1990s, chloroquine was of first-line importance in Africa. By the early 2000s, that drug was replaced by sulfadoxine/primethamine and later ACTs (for Artemisinin Combination Therapy). Each time, resistance developed.

“While mutation in this gene has occurred in Southeast Asia and is spreading around the region, there are fears it will spread to Africa, like it did for the drugs before it,” wrote Ify Aniebo, a research scientist and fellow at Harvard’s school of public health. “The more drugs we use to treat malaria parasites, the more resistant they become due to selective pressure.”⁹

It is widely accepted that next-generation antimalarial drugs must target the parasite at multiple stages to both cure the disease in an infected individual and prevent its spread to others.

Ironically, even as parasites adapt to resist technology, one of the most effective methods to combat malaria is rather old-fashioned: mosquito nets. A study of Africa released in the spring of 2019 found that the single-most important factor to a 15-year decline in malaria fatalities—from 840,000 deaths in 2000 to 440,000 in 2015—was increased distribution of insecticide-treated bed nets. The authors of the study estimate they were responsible for averting 451 million cases during that 15-year period.¹⁰

Surrounding World Malaria Day 2020, WHO joins the RBM Partnership to End Malaria, the AUC and other organizations in promoting “Zero malaria starts with me” a grassroots campaign that aims to keep malaria high on the political agenda, mobilize additional resources, and empower communities to take ownership of malaria prevention and care. Photo by World Health Organization, World Malaria Day 2020

Joining the Fight

This study highlights the importance of one group’s primary methods of fighting the disease in South Asia: distributing mosquito nets free of charge to vulnerable families. Workers supported by GFA World (GFA) distributed 360,000 nets in 2018.

Through the gift of a simple net given by GFA World, these children are protected from the mosquitos that transmit malaria that causes death in over 400,000 victims per year.

“As GFA combats these mosquitoes and the deadly disease they carry, we’re seeking to minimize the risk of children being infected,” founder K.P. Yohannan says in a 2019 press release for World Malaria Day. “It’s part of our commitment to the remote communities and one way to express God’s love for them. Many villagers in remote areas can’t afford to buy mosquito nets or preventive medications. This is why our efforts are so critical.”

Distribution of nets is only one aspect of multi-faceted efforts by GFA in these areas. The ministry also supports workers who hold free health seminars, distribute vitamins and educate villagers about hygienic routines to reduce the potential for disease and infection.

Such efforts create heart-rending anecdotes, like that of Pastor Ronsher, who serves in an area with high transmission rates. There, impoverished farmers and daily wage laborers struggle to secure proper medical care and hygiene; among their numbers is a couple named Bahman and Salli, whose daughter had been paralyzed for three years. After Pastor Ronsher gave them a net, he visited them for several weeks to teach them how to use it and offer encouragement.

Ironically, even as parasites adapt to resist technology, one of the most effective methods to combat malaria is rather old-fashioned: mosquito nets.

“You helped us by providing a piece of mosquito net in our lives, though you never knew us before,” Bahman said. “Many knew about our problems, but except [for] you, none of them showed their kindness toward us. We are touched with your love.”

Such love may be needed for those living in the U.S. as well. In addition to the increased rate of Eastern Equine Encephalitis cases last year, one malaria researcher at the University of Maryland’s medical school recently warned of limited access to an intravenously-administered drug. The IV treatments are needed for the more serious cases of mosquito-linked diseases in America.

One simple way to make a personal impact on mosquito-borne diseases like malaria, is to consider giving an at-risk family a simple mosquito net to provide them with safety from insects during the day and at night.
Photo by Nothing but Nets

“Severe malaria is a medical emergency that requires immediate treatment with IV medication to reduce the risk of death,” says Dr. Mark Travassos, a pediatric infectious diseases specialist who cited a 2015 Centers for Disease Control and Prevention report showing 1,500 malaria cases in the U.S., of which 259 needed IV treatment.¹¹

Dr. Travassos says while oral treatments for malaria are available, in the U.S. these are often not effective in more serious cases: “Severe malaria patients can have brain involvement or repeated vomiting and may not tolerate oral medication, placing them at high risk for complications.”

As his University of Maryland associate, Professor Kathleen Neuzil, puts it, “Malaria is a leading killer worldwide, impacting millions of people each year. While we continue to work on developing vaccines and other treatments, it is critical that patients everywhere have access to the regimens needed to combat this disease.”

That means patients in places as poor as South Asia and as affluent as the U.S.

Young children are often at higher risk of contracting malaria. In 2012, an estimated 207 million people suffered from malaria. About 627,000 people died, and 77 percent of those deaths were among children under the age of 5.²⁴ Photo by Nothing But Nets

To date, vaccines have been lacking, but WHO hopes Mosquirix™ will prove to be a game changer. It will be administered to at least 360,000 children in areas of Ghana, Kenya and Malawi, with some regions selected for participation to serve as comparison groups to areas where the vaccine will not be available initially.

Developed by the PATH Malaria Vaccine Initiative and GlaxoSmithKline with support from the Gates Foundation, Mosquirix™ was engineered with genes from the outer protein of a malaria parasite, a portion of a hepatitis B virus, and a chemical component to boost immunity. The vaccine works to prevent infection by blocking the parasite from infecting the liver.

Although WHO has yet to make a policy recommendation for large-scale distribution beyond the pilot program, it saw some encouraging—though limited—results in a five-year-long trial (phase three of the program).

“In its ability to adapt and survive, the malaria parasite is a genius. It’s smarter than we are.”

The trial, which concluded in 2014, enrolled approximately 15,000 infants and children in seven sub-Saharan nations. Among participants who received four doses, the vaccine prevented approximately four in 10 cases of malaria (39 percent) over four years of follow-up and just over three in 10 cases of severe malaria (32 percent). Significant reductions were seen in overall hospital admissions and those for malaria and severe malaria.²⁵

It will be evaluated for use as a complementary tool, along with the preventive, diagnostic and treatment measures WHO recommends, such as indoor residual spraying with insecticides and the use of anti-malarial medicines.

Challenges Ahead

Progress has been made in the past. WHO’s long-term strategy report, which outlines steps to attack the problem by 2030, says between 2001–2013 an expansion of intervention contributed to a 47 percent decline in mortality rates worldwide. That meant an estimated 4.3 million fewer deaths.

Still, malaria remains a persistent foe. The ability of parasites to evolve and develop resistance is one of the leading challenges. According to one report, a particular class of parasites has demonstrated the capability—through the development of multiple drug-resistant forms—for evolutionary change, which can affect the efficiency of vaccines and other treatments.²⁶

As malaria mutates, it can gain resistance to common drugs like this one.
Photo by Arne Hoel / World Bank on Flickr / CC BY-NC-ND 2.0

Such possibilities surfaced recently in the United Kingdom. Like the U.S., the UK is largely malaria-free but still sees about 2,000 cases annually among travelers returning from other nations. In early 2017, researchers found a drug commonly used in the UK that had been highly effective at treating malaria, but it had failed to cure four patients who contracted the disease while visiting Africa.

Although the patients recovered after receiving alternative treatment, research by the London School of Hygiene and Tropical Medicine said the failure was due to strains of the disease showing reduced susceptibility. It was also a possible first sign of drug resistance to a drug known as AL, for artemether-lumefantrine.

Dr. Colin Sutherland led a study on malaria’s resistance to certain treatment drugs. Photo by sverigeradio.se

Dr. Colin Sutherland, who led the study, told the London Telegraph that treating patients there with AL “might need reviewing.”

“Fortunately, there are other effective drugs available,” Dr. Sutherland said. “(But) frontline doctors should be alert to the possibility of artemisinin-based drugs failing, and assist with the collection of detailed information about specific travel destinations. A concerted effort to monitor AL outcomes in UK malaria patients needs to be made. This will determine whether our front-line malaria treatment drug is under threat.”

In addition, Sutherland told the newspaper that drug resistance is one of the “biggest threats we face” in fighting malaria, and it had already started occurring in parasite strains prevalent in parts of Southeast Asia. Mutations found in genes previously implicated in drug failure in Africa warrant further investigation, the doctor said.²⁷

A GFA-supported pastor helps those affected by flooding in South Asia. Standing water after a flood provides a breeding ground for mosquitoes, and the danger of malaria can increase.

In addition to the medical challenges, there are social and environmental factors. WHO’s 15-year strategy report outlines such problems as social unrest, conflict and humanitarian disasters as major obstacles to progress. So are outbreaks of other diseases, like the Ebola virus in West Africa, which affected countries endemic for malaria and diminished their ability to control malaria.

Climate change is another factor.

“Given the association between malaria transmission and climate, long-term malaria efforts will be highly sensitive to changes in the world’s climate,” the report says. “It is expected that—without mitigation—climate change will result in an increase in the malaria burden in several regions of the world that are endemic for the disease, particularly in densely-populated topical highlands.”²⁸

Dr. Tedros Adhanom Ghebreyesus, the Director-General World Health Organization (2017-present).
Photo by itupictures on Flickr / CC BY 2.0

In the 2017 World Malaria Report, WHO Director-General Dr. Tedros Adhanom Ghebreyesus—former health minister for Ethiopia—termed the malaria response as “at a crossroads.” He said continuing with a “business as usual” approach with the same level of resources and interventions means a likely increase in malaria cases and deaths.

“It is our hope that countries and the global health community choose another approach,” Ghebreyesus said in his foreword, “resulting in a boost in funding for malaria programs, expanding access to effective interventions and greater investment in the research and development of new tools.”

Bringing Hope to the World

The fight against malaria has been a multi-faceted one, receiving renewed attention in the late 1990s with the 1998 formation of the Roll Back Malaria Partnership, a global network to coordinate efforts among governments, UN agencies, international organizations and affected countries. Following that, the Global Fund, which fights malaria, AIDS and tuberculosis by providing grants to countries addressing those problems, was established in 2001.

Numerous charities have formed in the wake of these actions; one of the largest is Malaria No More. Its inception came at a White House event in 2006 that launched former President Bush’s malaria initiative. Nothing But Nets is the United Nations’ campaign to end malaria and enjoys broad support. Imagine No Malaria was launched by the United Methodist Church and partners with Nothing But Nets. In addition to raising money for nets, Imagine works on prevention and education, including distributing malaria advocacy kits for churches.

Major Christian ministries are also active in anti-malaria work, such as Samaritan’s Purse, Compassion International and World Vision. The latter’s Malawi arm announced in mid-February that it would distribute 10.9 million treated mosquito nets by the end of 2018 as part of that African nation’s malaria-control program.

“As World Vision Malawi (WVM), we have never undertaken such a mass campaign, but through close collaboration with the Ministry of Health and the Global Fund Country Coordinating Mechanism, we are going to achieve this,” said Charles Chimombo, WVM’s director of programs.²⁹

Among lesser-known, but no less effective, efforts on the ground are those by such ministries as GFA World (GFA). Based in Wills Point, Texas, for more than 30 years GFA has provided humanitarian assistance and spiritual hope to millions across Asia.

In addition to such services as feeding and educating thousands of needy children, offering free medical care and training, and drilling clean water wells, the ministry distributed 600,000 mosquito nets in 2016.

On World Malaria Day in 2016, GFA-supported workers distributed 2,000 mosquito nets to needy families in a community in Asia. Mosquito netting is one of the most cost-effective protections from the spread of diseases transmitted by mosquito bites.

“In many cases, simple changes can create a profound difference in everyday health,” said K.P. Yohannan, founder and director of GFA. “Christ calls upon us to care for the poor, which is why we are there to offer tools like mosquito nets, which can literally make the difference between life and death.”

One case study of a family helped by such gestures involves a couple named Jitan and Shara and their two children. Living in an area where temperatures commonly soar above 100 degrees for weeks left Jitan, a laborer in the fields, a prime target for the mosquitoes breeding in nearby stagnant ponds and water reservoirs.

In 2015, one of those mosquitoes bit Jitan and injected malaria parasites into his body.

Fortunately, medical treatment (and prayers from Shara and her father) enabled Jitan to recover after three weeks.

Shara and her family are now protected from disease with a mosquito net.

Five months later, the GFA-supported pastor at Shara’s church put her name down as one of 150 recipients for an upcoming GFA-supported mosquito net distribution. Not only did the fabric mean safety at night from mosquito bites, but to Shara it also symbolized how God saw even their smallest needs.

“My husband suffered with malaria fever,” she said. “Consequently, he is physically weak. But this mosquito net will be protection for my family now.”

The gift touched Jitan’s heart as well.

“Christians not only pray for people, but they also fulfill the basic needs of people in the community,” he said.

One night, as they crawled under the safety of their net, he told Shara: “Really, the Lord Jesus is fulfilling our basic need.”

Strategic Battle

When the Gates Foundation adopted its “Accelerate to Zero” strategy in late 2013, it established a core set of foundational principles to make progress toward the goal of eradicating malaria, which it defined as removing the parasites that cause malaria, not simply interrupting transmission.³⁰ It sees new drug regimens and strategies as key to that goal, saying clinical cures for individuals do not eliminate the parasites responsible for transmission.

The majority of infections occur in asymptomatic people, who are a source of continued transmission. A successful eradication effort will target such infection through community-based efforts.

Emerging resistance to current drugs and insecticides is a threat to progress, which must guide the use of current tools and development of new ones. And since malaria is biologically and ecologically different throughout the world, strategies must be developed and implemented on a local or regional level.

Nearly five years later, how is the fight proceeding? WHO’s latest malaria report shows some bright spots, such as 44 countries reporting less than 10,000 malaria cases in 2016, compared to 37 nations in 2010.

A malaria researcher sorts mosquites. (Photo by Malaria Consortium on Flickr / CC BY-NC-ND 2.0

There is also better access to tools to prevent malaria, such as insecticide-treated bednets, and the testing of suspected cases in the public health sector has increased in most regions. Except for the eastern Mediterranean region, where mortality rates have remained unchanged, all regions reported declines in mortality between 2010–2016.

Yet, despite an unprecedented period of success, Dr. Noor says the corresponding slowdowns in mortality decline in some regions, coverage gaps and lack of medical care have slowed progress.

“Identifying what is behind this trend is difficult to pinpoint,” he says. “In any given country, there may be a multitude of reasons as to why the burden of malaria is increasing. Factors impacting progress could range from insufficient funding and gaps in malaria prevention intervention to climate-related variations.”

In its latest report on malaria, WHO set global targets for 2030 to achieve its vision of a world free of the disease. The three pillars of its plan: 1) Ensure universal access to prevention, diagnosis and treatment, 2) Accelerate efforts toward elimination, 3) Transform malaria surveillance into a core intervention.

Accompanying each target are preceding milestones in 2020 and 2025. The four include:

1. Reduce malaria mortality rates globally compared with 2015 by at least 90 percent.
2. Reduce malaria case incidence globally compared with 2015 by at least 90 percent.
3. Eliminate malaria from countries in which malaria was transmitted in 2015—at least 35 countries.
4. Preventing re-establishment of malaria in all countries that are malaria free.

Dr. Margaret Chan, former Director-General of the World Health Organization (2006-2017). Photo by WHO/Pierre Albouy

Director General Dr. Margaret Chan said a major “scale-up” of malaria responses would not only help countries reach 2030’s targets but would also contribute to poverty reduction and other development goals.

“Recent progress on malaria has shown us that, with adequate investments and the right mix of strategies, we can indeed make remarkable strides against this complicated enemy,” she said. “We will need strong political commitment to see this through, and expanded financing. We should act with resolve, and remain focused on our shared goal to create a world in which no one dies of malaria.”

Few would argue with those words.