Q&A: We will win the fight against malaria by being innovative - Dr. Robert Newman

Paul Adepoju
Malaria, though preventable and totally curable remains a leading cause of infant mortality in Africa despite numerous efforts by various local and international organizations including the World Health Organization.

 HealthNewsNG caught up with Dr. Robert Newman, Director, Global Malaria Programme at the World Health Organization. He gave an extensive and in-depth overview of malaria control in Africa, with focus on the achievements recorded, new options the WHO is considering and how the disease can be totally eradicated.

HealthNewsNG: Looking at the past ten years, how would you assess the journey so far in malaria control in Africa?

Robert Newman: I think Africa has done an amazing job over the past 10 years. Compared to when I first went to Africa in 1995 to where it is today in 2013, there has been several major strides. What made it possible is increase in political commitment and that was evident in the just concluded Abuja summit. There has also been increase in financial commitment. Political commitment is critical but without financial resources, nothing much could be achieved.

There has been increase in finance worldwide but most of it has been in Africa which has brought tremendous results such as scale up of preventive measures like long-lasting insecticide-treated mosquito nets, rapid diagnostics and effective treatment with combination therapy.

So far, the result has been impressive – 33% decline in malaria mortality in Africa over the past decade. This is great news but we should also realize that there is still a lot of work to be done for a disease that is entirely treatable and preventable.

90% of the people that die from malaria are from Africa including children under the age of 5. Those children are counting on us to make sure that the life-saving commodities such diagnostics and ITNs get out to everywhere they are needed.

Another challenge is how do we measure the impact of the interventions? And there is also the issue of surveillance. So it’s not just about collecting data alone; it’s about collecting data, analyzing it and acting on it.

At the local level, we need to understand what is responsible for the results we are having. If the prevalence is increasing, we need to understand why this is so – are people not taking their medicines or are the drugs not working? Or are we just having a rainy year with lots of mosquitoes? We ask questions like what is the data telling me about the situations around me and what can I do about it?

One thing that I’ve observed while covering malaria-related issues in rural areas across Nigeria is that despite the billions of dollars spent on various malaria-focused projects annually, many people at the grassroots – those that are the major focus of the various malaria control initiatives, still don’t know essential basic information concerning malaria. We both know this is potentially dangerous both in the short term and long term. So, apart from the various efforts, measures and commodities that are being pushed out, making sure that people hear and act right is very essential to global malaria control. How will you assess the current level of malaria awareness in Africa?

 You’ve raised a very important point which is that global malaria control can’t be at global, continental or national level, it has to be at every level all the way down to affected communities. I remember when we used to do questionnaires and we ask people what causes malaria? Very few people got it right. But today, in most places and no matter the level, the situation has changed a lot. Most of the people do understand what causes malaria. 

About 55% of African households have ITNs. Awareness is much higher than it was before. But again, the question now is "do you want to view the glass as half full or half empty?" I think we have to look at the glass as half full. I look at it like whoa, look how far we’ve come.

But that doesn’t mean we can’t do better. To ensure improved awareness, we have to get all sectors involved, including the private sector especially in Nigeria where a huge proportion of the population get their healthcare services from the private sector. So the private sector has to be involved.

Finally, community healthcare workers are a huge potential force and there is already a working model in countries like Ethiopia which has about 30,000 community health workers. These are essentially people that are paid to work at all levels up to the village level.

When you have people like that working at all levels, they become an important asset not just in providing healthcare services but also to advocate about healthcare in general; making people know what their major health issues are, let their voices be heard, let them know they are central to the process and project.

Nigeria recently passed a federal bill into law – the integrated community case management bill which brings together the treatment of malaria, diarrhea and pneumonia. Those three are part of the leading killers of children in Africa. The community health workers can help increase the level of advocacy at the grassroots on these health conditions; they can also help affected individuals get access to treatment. This is the kind of plan I believe can work.

You are pediatrician, why did you choose to pitch your career tent with malaria?

I’m a pediatrician but I’ve dedicated myself to malaria because despite the fact that it is the single major child killer disease, it is still treatable.

 

Multiple standardization, wrong diagnosis and missed diagnosis arising as a result of multiple and poorly synchronized efforts to control malaria often lead to conflicting standards even in tasks as simple as identifying trophozoites of the malaria parasite. When the various positive-band-showing kits were brought to Africa, another challenge was presented which was how to maintain standard control for kits which has to be kept under specifically defined conditions in rural areas that can’t provide such conditions. In the light of these and several other challenges, what measures have been put in place by the WHO to help maintain diagnostic standard at all levels in Africa?

This is a complex technical question. Malaria diagnosis is in 2 main streams. One, we’ve always made microscopy the standard method. This is applicable in diagnostic centers that have microscopes, but we can’t get microscopes to every community and every clinic including private practitioners. This is where rapid diagnostic tests come to play.

These tests that cost about 50 Cents a piece are very accurate and easy to perform. You put a drop of blood on the rapid test kit and a drop of reagent to develop it. Within 15 minutes there is a line which could be easily read whether positive or negative.

At the global level, we have made a series of recommendations about which tests are acceptable based on the published result of our annual product testing. Following our recommendation, it is now left to the countries to procure from the list of recommended products. Even when they do, they also need to ensure that the right product is being shipped to the country. So they are expected to carry out special testing on the batch of products received. Nigeria is one of the countries in Africa with such capacity.

There is also the need for adequate personnel training and supervision by well-trained experts.

Remember that once upon a time, people treated every fever like it was malaria. That was probably true until several years ago. That’s not true anymore. We now have ITNs and several other control measures, most of today’s fevers are no longer malaria. So it’s more important now that we do diagnostic tests.

On World Malaria Day, WHO Director General, Dr. Margaret Chan travelled to Libya to launch the T3 initiative which suggested that every suspected case of malaria should get a diagnostic test, every confirmed case should be treated with confirmed medicine and the disease should be tracked in surveillance (T3 – test, treat and track).

For several years now, chloroquine according to WHO shouldn’t be an option in malaria chemotherapy. But till today, it is still available over-the-counter in many African countries including Nigeria where a recent survey we carried out at HealthNewsNG showed that despite its ban, chloroquine is even more widely used than the recommended combination therapy. How is the WHO handling this?

This is where WHO’s work stops and the country’s work has to begin. We have long recommended not using chloroquine in Africa; we have said it’s not effective. The thing about chloroquine is that it only has the intrinsic property of reducing the fever; it doesn’t kill the malaria parasite. But many people think chloroquine is effective because the fever has dropped but the drug has done nothing about the malaria. It is still there. This feature has allowed many people to insist it works for them while in the real sense it is not useful.

It’s a big problem and it’s one that I think requires urgent action from any country that still maintains chloroquine in the system. In the case of many countries there is already a policy discouraging chloroquine usage so it’s not a problem of policy but the enforcement of policies.

This is the challenge and we are turning back to the countries and say they should work with drug regulatory authorities that have the enforcement capacity; they must ensure that combination therapy totally replace chloroquine in the treatment of malaria.

To a large extent, the cost of combination therapy is comparatively higher than that of chloroquine. This to a large extent is the reason why many people in the developing nations still use and trust chloroquine. What has the WHO done to significantly bring down the cost of combination therapy so that citizens of the endemic nations can have easier and much affordable access to the drugs? What of the viability of the free treatment option?

It’s a really challenging issue but to say the truth, the price of the combination therapy has reduced drastically. The prices are now a fraction of what they once were. In many countries, malaria treatment has become a public health issue. We don’t charge people to immunize them so why should we charge them to treat their children for malaria? 

Treatment in most developing countries is free-of-charge especially for children under the age of five. The more we can make free treatment available, the more we will be able to drive ineffective drugs out of the system. We need to look at the longer view of cost.

The longer we allow drugs like chloroquine to be in the system, the harder it will be to get rid of malaria because those people are not getting effectively treated. They’ll keep transmitting malaria through mosquitoes to somebody else. We need to take the longer view which is that chloroquine has a very high cost on the society over a long period of time. 

We need public education, regulation and enforcement; we need to continue to work at a global level to make these medicines as affordable as possible. I don’t think the cost is unaffordable at the society level to ensure that everyone with confirmed malaria actually gets adequate treatment.

The use of mosquito coils has become highly controversial because of the issue of carcinogenic contents which put mosquito coils on the same threat level as cigarettes. However, they are still highly used in many regions of the world, most especially in Africa. What is the WHO's position on the use of mosquito coils?

I don’t have any official position on mosquito coils. I know they tend to be used by many individuals and there are different programs that have been put into place so I don’t have a formal recommendation on the use of coils. 

I know there are some ongoing studies on coils in a number of settings not just in Africa but in some parts of Asia but I don’t have the results of those studies. So I don’t have a formal position for the Global Malaria Programme on the use of mosquito coils at this point.

You said in Abuja that malaria vaccine will be ready 5 years from now. I’ve been following several local malaria vaccine projects including those that are testing MSP-1 as a possible vaccine candidate. With the knowledge of cell biology and population immunogenetics, we know we should be concerned with overall efficacy of the vaccine in many other populations that are extensively different genetically from the test population. This makes me, like many in the science wonder whether the RTS,S will only be effective for a limited number of nations.

There is currently no license vaccine right now, the vaccine under review now is at Phase III clinical trial and is called the RTS,S vaccine and it is being tested in 11 different sites across 7 different countries in Africa. The trial is using this vaccine in addition to ITNs. The vaccine, even if it is successful, will not be a replacement for present strategies, it will rather be an additional strategy.

There have been 2 papers – 2 batches of results from this trial already, 1 looking at the efficacy in preventing malaria in children between 5 and 17 months of age when they received the vaccine, and the second batch of results in younger children who received the vaccine along with their normal insect vaccination. Now the trial is ongoing and following the children up to 30 months after they were immunized which is about 3 years.

We at WHO are following the trial like many people and we have an expert committee that sits once in a year to review the results emerging from this trial. The final data from this trial would be available in 2014 and our committee at the WHO will meet to give a recommendation one way or the other in 2015 so we shouldn’t be expecting any recommendation before 2015.

What that recommendation will be will be dependent on what the final data from the trial show and what the committee makes of those data. These would be people who have real expertise in vaccination and with expertise on malaria who are working together to consider it through both perspectives as a biological control tool, as a vaccine and together, this group of experts would recommend to WHO how we should use the vaccine and we will make a recommendation and we would urge the countries to make use of it.

So yea we are watching with great interest. Clearly the whole world, myself included would love to have an additional malaria control tool and we are just expecting this clinical trial to finish before we can make a recommendation.

It’s not just politics that lobbyists dominate; they are also in the health sector. Is the WHO under any pressure to make the vaccine available earlier than what the due process clearly states?

Not at all, I think that’s really the power of WHO. We are a member states’ organization. I feel that people know that we are going to evaluate all the data so that our recommendation will be in the best interest of the people that will benefit from the vaccine based on what the data show and personally, I've not had any pressure from any sides. Interest groups, yes, but everybody is interested, so am I. People should let the data speak and the people that will review the data.

This is a process that has gotten respected integrity over the years.

The use of genetically modified mosquitoes in malaria control is another extensively argued issue with very strong opposition coming from Europe while the US is more open to it although Africa is the worst hit by malaria. Conflicts aside though, is the option still on the table?

Yea. There are several researches currently going on but we don’t have any research that has been submitted to us for policy consideration.

Innovation is important in fighting any disease. Part of the fight against malaria is to be steps ahead of the parasite and ahead of the mosquito. I think scientific innovation and new approaches are needed such as a new vector control like the genetically modified mosquitoes.

Will it be a vaccine or drug that works in a different way? But what I know is we always win things by being innovative. It is also interesting to meet people working in the same line as yours.

Ten years from now, where will we be in the global malaria programme? 

Years from now I think we’ll continue the fight against malaria.