Malaria progress stumbles, but new tools offer hope
Authors: None The Lancet Microbe
Journal: The Lancet Microbe (2021)

The estimated number of malaria cases increased from 227 million in 2019 to 241 million globally in 2020, and the number of deaths increased from 558 000 to 627 000, according to WHO's 2021 Malaria Report, published on Dec 6. Since 2000, the number of malaria deaths had steadily decreased from 896 000 deaths, as had the case incidence (from 81 to 59 cases per 1000 population at risk). This year's Report is the first to mark a reversal in the progress made against the disease. This reversal is largely attributed to the impact the COVID-19 pandemic on malaria services in endemic countries, which included disruptions to manufacturing and supply chains (both between and within countries) of health commodities and consequent cost increases—affecting affordability at a time of enhanced economic instability. Restrictions on the movement of people is likely to have reduced the availability of health-care workers, and fear of contracting the virus is likely to have discouraged individuals from seeking care. These factors combined led to decreases in outpatient attendance of health-care facilities and in the number of malaria tests performed, and to fewer insecticide-treated nets distributed than planned. Although the COVID-19 pandemic is considered the lead cause of the worsened malaria burden in 2020, WHO's Report highlights that there were also other contributing factors, such as COVID-19-unrelated health or humanitarian emergencies in malaria-endemic countries. Also, insufficient investment has meant that the 2020 milestones set out in WHO's global technical strategy for malaria 2016–30 (GTS) were not met, with both mortality and incidence targets being off by about 40%. Another document published jointly by WHO and The Global Fund to Fight AIDS, Tuberculosis and Malaria on Dec 9—State of inequality: HIV, tuberculosis and malaria—has, for the first time, systematically explored and highlighted how socioeconomic, demographic, and geographical inequalities impact on the burden of these three diseases by affecting access to prevention and treatment services. Although these inequalities are not new, they are likely to have been exacerbated by the COVID-19 pandemic. Unsurprisingly, those with low levels of education, with low income, and who work in agriculture are at the highest risk of malaria, and, in particular, the poorest children younger than 5 years whose mothers have lower educational levels and who live in rural settings are those for whom care is most unlikely to be sought promptly when febrile. Although the global fight against malaria appears to have been set back, WHO's Report also bears some positive news: progress towards elimination is being made in several countries (eg, Belize, Cape Verde, Iran, and Malaysia reported zero indigenous malaria cases for at least the second consecutive year) and two countries, China and El Salvador, were certified malaria-free in 2021. Furthermore, this year, WHO has recommended that the RTS,S malaria vaccine—the first antiparasitic vaccine available for use in humans—be used in children who live in regions with moderate-to-high transmission for the prevention of Plasmodium falciparum malaria, and promising (if preliminary) results have been published for two additional tools that could in future be used against malaria: another vaccine (the low-dose circumsporozoite protein-based vaccine R21 plus Matrix-M) and a monoclonal antibody (CIS43LS). The 2020 increased global burden of malaria and the unmet GTS targets are cause for concern, but it should be noted that early predictions of the effects of the COVID-19 pandemic on malaria were substantially starker, suggesting that the burden could have more than doubled compared with 2019. That such drastic consequences could be averted and that there are some success stories are a testament to the efforts made by malaria-endemic countries to mitigate the effects of the pandemic, in line with recommendations made by WHO in April, 2020, and with the support of The Global Fund's COVID-19 Response Mechanism. Although the COVID-19 pandemic is far from over, these efforts must be upheld and enhanced. The authorisation to use the RTS,S vaccine has expanded the arsenal of prevention tools available, and the State of inequality document offers clear guidance on populations and factors that require prioritisation. If the global community genuinely wants to succeed in ending malaria, it just has to decide to do it. Past success at tackling malaria and current inroads against COVID-19 show that success or failure in dealing with major infectious diseases is primarily a matter of choice. For the Global Fund Strategy (2023–28) see https://www.theglobalfund.org/en/strategy-development/global-fund-strategy-2023-2028/ For the Global Fund Strategy (2023–28) see https://www.theglobalfund.org/en/strategy-development/global-fund-strategy-2023-2028/ Vector control strategy for Anopheles stephensi in AfricaGlobal challenges and opportunities for malaria control were perfectly outlined in The Lancet Microbe's Editorial,1 emphasising the effects of the COVID-19 pandemic; growing political instability and violence; and socioeconomic, demographic, and geographical inequalities on malaria burden. Another serious threat to the global health effort in Africa is rapidly developing: the emergence and spread of the invasive malaria vector, Anopheles stephensi (An stephensi).2 An stephensi is a competent vector of Plasmodium vivax and Plasmodium falciparum and a probable vector of zoonotic malaria parasites (appendix p 1). Full-Text PDF Open Access