Malaria: on the brink of a breakthrough?
As the heads of the Commonwealth gather in London, Anne Gulland looks at why malaria will be on the agenda
Orlando Brooke was just 18 and on a gap year in Africa when he was struck down by malaria. His symptoms appeared as he attempted to scale Kilimanjaro in Tanzania and, mistaking the symptoms for altitude sickness, he descended the mountain. “I got on to a bus, but within an hour I was feeling so ill that I got off. I was in the middle of the African bush and I just crumbled by the side of the road. I had no strength. I felt awful – imagine the worst flu you’ve ever had and times it by 10,” he says.
Fortunately he was picked up by a kindly local, Andrew, who took Brooke to hospital in the nearby town of Arusha.
“A doctor took my blood and then a few hours later came back and said ‘Mr Orlando Brooke, you have malaria’.
“I thought this was my death knell – I thought I was going to die,” says Brooke.
Like many travellers, Brooke had been taking doxycycline anti-malaria pills, but they are not 100 per cent effective. He thinks he got the disease on the bus journey to Kilimanjaro, where he had been “savaged” by mosquitoes during the night.
After a week of treatment, he felt stronger, but his weight had dropped to just 7st 7lb. When his friends finally tracked him down, they barely recognised his pale, thin frame.
He returned to his teaching job in Zambia and didn’t tell his family about his near-death experience until he returned home.
Fifteen years later, Brooke, now an actor in London, still raises money through sponsored runs for the charity Malaria No More.
As a relatively well-off westerner, Brooke knows he was lucky when he became ill. “I was able to pay for the drugs and the hospital treatment – a lot of local people can’t afford it,” he says.
A global killer
Whether it’s teenagers on gap years, or tourists turned intrepid travellers on bucket list trips of a lifetime, many of us will visit countries where malaria is still a very real problem.
Most of Africa is affected by the disease as are south-east Asia, Central and South America, the Dominican Republic and Haiti and parts of the Middle East.
In 2016, more than 1,600 people were treated for malaria in the UK and six people died. Most of those, says Public Health England, did not follow advice on how to avoid the disease, such as taking anti-malarial drugs like mefloquine, doxycycline and chloroquine, covering up and using insect repellent. Anti-malarial drugs can reduce the symptoms of the disease but, as Brooke and many other travellers have found to their cost, they are not a magic bullet. Often they are not straightforward; some of them have to be taken one or two weeks before arriving in a malaria-infected country and up to four weeks after leaving, tempting some less conscientious travellers to give them up before finishing the course. Other drugs, famously mefloquine, also known as Lariam, can have some side effects, such as anxiety and hallucinations, and people with a history of mental health problems are advised not to take it.
In 2016, the last year for which data are available, there were an estimated 216million cases of malaria worldwide. Of those infected, a staggering 445,000 died – 1,219 lives lost every day or nearly one a minute.
After a big push to eradicate the disease in the Fifties and Sixties, it has surged back with a vengeance, gaining a particular stranglehold in Africa, which now accounts for about 90per cent of all cases. A second push over the past decade was initially successful, reducing the number of cases by about 20per cent in just five years, but progress has stalled.
But a new fightback is planned. The World Health Organisation (WHO) believes we are at a “crossroads” and advances in science mean that it should be possible – with the right focus, funding and international co-operation – to eradicate the disease completely by 2030.
Six of the 10 countries with the highest incidence of malaria are members of the Commonwealth, and leaders at this week’s Commonwealth heads of government meeting in London are committing to wiping out the disease once and for all. But how?
Genetically modified mosquitoes
Malaria is a complex disease and to fight it, experts are waging war on three fronts: the malaria parasite, the mosquito that carries it and the human behaviours and living conditions that can feed it and cause it to spread.
Pedro Alonso, the director of the global malaria programme at the World Health Organisation, is in search of a “game-changer” – a Continued on page 21
vaccine, treatment or control technique that will finally eradicate the disease.
Many global health experts are pinning their hopes on work by an international consortium of researchers, led by Imperial College London.
Only the female mosquito transmits malaria and researchers are using a state-of-the-art geneediting technique to interfere with the Anopheles gambiae mosquito – one of the major transmitters of malaria – so that it only carries male eggs. This is called gene drive, where a whole species is “persuaded” to adopt a gene. Researchers believe that after 20 generations – around two years – this modification will set in, and this genetically modified mosquito will eventually die out.
Delphine Thizy, the stakeholder engagement manager of the project, says: “It’s going to be another decade before this is ready to use. But in another decade, malaria will still be here.” Other genetic tools include
sequencing techniques. Researchers at the Wellcome Sanger Institute in Cambridge have mapped 4,500 genes of 500 malaria parasites to create the Malaria Cell Atlas: an online database freely available to researchers around the world to help them work out
precisely which drugs and vaccines are effective and which aren’t.
Vaccines and treatments
Vaccines have always been key. From this September, children in Kenya, Ghana and Malawi will get the first doses of the RTS,S vaccine, developed by the British pharmaceutical giant Glaxosmithkline (GSK).
While the launch of the vaccine is a landmark in the war against malaria, in trials it only reduced the number of deaths by 40 per cent. It also has to be given in four doses, with the fourth administered 18 months after the third.
A single-dose vaccine is the holy grail – researchers are not there yet but there are promising treatments in development that could provide some long-term protection, as well as helping fight drug resistance: a prospect that is a real worry for malaria researchers and doctors.
At present the main treatment for malaria is artemisinin-based combination therapy (ACT). In south-east Asia, where malaria is less widespread, malaria parasites have developed drug resistance, which has spread from south-east Asia to Africa. The development of new treatments is key in ensuring that researchers stay one step ahead of the parasite.
The development of new treatments mean that there are now five combinations that can be used to treat malaria, giving doctors more choice if resistance becomes an issue. There are also new formulations for children that are easier to administer.
But there is still a long way to go. Pedro Alonso of WHO is clear that funding and political will are now both crucial to the fight. He hopes that this week’s Commonwealth meeting will see malaria return to the top of the political agenda for leaders and international donors.
“Malaria remains one of the big killers of the world,” says Alonso. “We have to eradicate it – it’s time to tick that box.”
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