For a disease that has more than 200 million cases worldwide, Malaria kills less than half a million annually – most of them in Sub-Saharan Africa. A great part of this reduced death toll is due to the effectiveness of two treatments; Artemisinin-based Combination Therapy (ACT) and chloroquines, which work on the strains plasomodium falciparum and p. vivax respectively.
But thousands of miles away in Thailand, Gilles Delmas has a frightening message for the future of the global Malaria eradication program.
We know that within the next two to five years, the medicines we are using now will be useless.
Gilles heads the Malaria Elimination Task Force in Thailand, as part of the Shoklo Malaria Research Unit (SMRU) in Thailand, affiliated with the University of Oxford. His concerns reflect the latest findings in Vietnam, published in the Lancet journal as a letter. It states:
The spread of artemisinin resistance in Plasmodium falciparum and the subsequent loss of partner antimalarial drugs in the Greater Mekong subregion presents one of the greatest threats to the control and elimination of malaria.
Their research is the latest on the global trend of ‘superbugs’ – strains of disease that have developed immunity against the medicines we use to treat them. In the case of Malaria’s P. falciparum strain, combination therapy relies on a fast-acting Artemisinin drug being paired with a long-acting partner drugs. What first emerged in Cambodia, the C580Y strain, was initially only resistant to Artemisinin. Now, it’s acquired immunity to the partner drug, piperaquine, as well.
Across the Greater Mekong region, traditional treatments for P. falciparum have failed; in parts of Cambodia, Thailand, Laos and Vietnam. To make matters worse, drug resistant strains of P. vivax have also emerged in Myanmar; with some incidence on the border with India as well.
The border incident brings a dangerous sense of deja-vu. In the 1950s, a strain of chloroquine-resistant Malaria started spreading in both India and any parts of Africa. The death toll ran into the millions.
India faces a million cases of Malaria each year, with most fatalities occurring in rural areas. Though the country is making progress on its goal to eradicate Malaria by 2030, there remain significant challenges in terms of building infrastructure and promoting prevention. The threat of drug-resistant Malaria is that it could undo much of the progress that has already been made worldwide – where Malaria-related deaths have dropped by a third for both adults and children.
Most – that is 90 percent – of global deaths from Malaria take place in sub-Saharan Africa. With so many countries now displaying drug-resistant strains, there is a real risk that tourists or even aid workers could bring the deadly disease to the world’s most vulnerable region. This year saw the first documented cases of British patients being afflicted by drug-resistant strains – acquired during their travels in Angola, Liberia and Uganda.
The death toll from drug-resistant infections every year totals 700,000 (the figure includes Malaria and other diseases). But it’s a figure that could go into the millions barring immediate treatment. This year, the World Health Organisation released its first list of infections that require new anti-biotics. For now, Malaria is not in the high priority.
As Malaria evolves, so does our understanding of it. Recent studies have shown that the parasite causing the virus adjust their reproduction based on the victim’s calorie intake. Those who are malnourished will take in fewer calories – and the disease will spread less effectively.
There is some hope for newer forms of treatment. Significant progress was made in Myanmar after mass-treatment programs took a preventative approach. Mass treatment is effective, as it mitigates the one factor that makes drug-resistant strains hope from stronger to weaker immune systems – diversity. South East Asia has a high level of internal migration, and Myanmar was no different. It’s mass treatment programmes have consequently reduced the number of cases encountered during the rainy season from 290 to 46 – in a single year.
Elsewhere, the SMRU suggests that organisations make best use of ACT before the disease evolves to make it obsolete. We have already seen how the Malaria parasite makes infected humans more attractive to other mosquitoes – spreading the disease further – while also egging infected mosquitos towards humans.
One proposed technique involves keeping the mosquito out of the equation altogether. A study comparing homes in South East Asia to those in Sub-Saharan Africa found that huts with Bamboo walls and screened windows were both cooler and more effective at keeping mosquitos out than the traditional mud huts prominent in Sub-Saharan Africa.
And though the newest strains are proving resilient towards Artemisinin, the plant that makes the compound isn’t giving up the fight yet. Research has found that a dried leaf variant of the compound cured 18 severe cases of ACT-resistant Malaria. Artemisia annua, also known as Sweet Wormwood, could remain a heavyweight fighter in the war against Malaria.
What will truly win this war is a global effort. Organisations need to take note of the work taking place around the world. For millennia, man has suffered from Malaria and the information asymmetry around it. In ancient times, the disease was blamed on everything; in Greece it was attributed to the star ‘Sirius’, in China to a trio of demons. As far back as 1856, the Somali people have known that Malaria was caused by mosquitoes – and were subsequently ridiculed by a British traveller for the belief. Yet, it was only in 1897 that a British medical doctor claimed the discovery.
Taking Malaria for granted – and the ongoing slowdown in fatalities – would belie the disease of its historic danger to mankind. It is without doubt the deadliest disease in history, killing Alexander the Great, six popes and according to some researchers, half of all the humans who have ever lived.
Humanity has never been closer to eradicating the disease for good. A successful global effort will make the 21st century stand out amongst all the centuries of human suffering at Malaria’s cause.
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