FROM EVIDENCE TO ACTION

By: Aly Diana

The American Society of Tropical Medicine and Hygiene (ASTMH) Conference was held at the Hy-att Regency Chicago in Illinois, USA, from October 18 to 22, 2023. This bustling event hosted 13 simultaneous sessions and attracted approximately 4,300 participants from over 130 countries. The conference covered a broad spectrum of topics, including mosquito-borne diseases, neglected tropical diseases, rarer conditions, and overarching global health challenges, such as climate change.

A focal point of the discussion was malaria, which is the main topic of this brief report. The Alan J. Magill Malaria Eradication Symposium, named in honor of the late Dr. Magill, a former ASTMH President and Malaria Director at the Bill & Melinda Gates Foundation, brought emerging challenges in malaria control and eradication to light. Dr. Magill’s strong advocacy for malaria eradication laid the groundwork for the strategies currently being explored and implemented.

David McGuire from the Innovative Vector Control Consortium emphasized vector control, a key method in reducing malaria’s burden, especially in Africa. He highlighted its crucial role in the broader strategy of malaria elimination. However, traditional methods like insecticide-treated bednets and indoor spraying campaigns are increasingly compromised due to the rise of insecticide resistance among mosquito populations. This resistance, particularly to the commonly used pyrethroids, has necessitated a shift to newer, more expensive compounds, placing significant financial strain on malaria control programs.

Keziah Malm from Ghana’s National Malaria Elimination Programme (NMEP) observed a trend of mosquitoes biting outdoors. This behavioral adaptation reduces the effectiveness of indoor-focused control measures, as it involves different mosquito species. New strategies are needed to address these changing patterns of malaria transmission.

Climate change and urbanization add further complexity to malaria control. Unpredictable rainy seasons, resulting from climate change, disrupt the timing and effectiveness of mosquito-control campaigns. The demographic shift from rural to urban areas also necessitates novel control strategies suitable for urban settings.

Financial constraints are heightened by the emergence of new tools, such as novel insecticides, drugs, and vaccines, intensifying the competition for limited resources. This scenario poses a significant challenge for national and global malaria control programs, which must strategically allocate and prioritize resources.

Gabriel Carrasco-Escobar proposed using satellite and drone imagery for more targeted mosquito control efforts, adapting to the changing ecological and behavioral patterns of mosquitoes. Supplemented by crowd-sourced data from mobile apps, this approach could lead to a more accurate understanding of mosquito populations.

Flaminia Catteruccia discussed innovative strategies to prevent malaria transmission without harming mosquito survival. These include using compounds that inhibit parasite transmission, genetically modified mosquitoes, and bednets infused with anti-malarial medications as alternatives to traditional insecticides. These strategies aim to disrupt the malaria transmission cycle rather than focusing solely on mosquito eradication.

The symposium emphasized the need for fresh thinking in vector control, resonating with Dr. Magill’s legacy of innovation and risk-taking. As the fight against malaria enters a new phase, marked by insecticide resistance, behavioral adaptations of mosquitoes, impacts of climate change, urbanization, and financial constraints, innovative, sustainable, and adaptive approaches are increasingly vital. The future of malaria control will likely involve a combination of technological innovation, strategic resource allocation, and a deep understanding of environmental impacts.

Target Malaria is revolutionizing the fight against malaria with its innovative communication strategies, particularly focusing on explaining the intricacies of gene drive technology, which aims to modify mosquito DNA to reduce transmission. Their operations span across Burkina Faso, Ghana, Uganda, and the UK, employing a variety of techniques to bridge the gap between complex scientific advancements and public comprehension. One of their standout projects is a collaboration with Jamie Perera, a sound artist and composer. Perera transformed data from gene drive cage trials into a sonification piece called “Swarm,” which was showcased at the Great Exhibition Road Festival in Lon-don. This unique approach, which earned the “Disruptive Communication” bronze award in 2023, provides an immersive experience for visitors, helping them understand how gene-driven mosquitoes could potentially reduce malaria mosquito populations.

In addition to technological approaches, Target Malaria places significant emphasis on community engagement through cultural mediums. In Burkina Faso, for instance, they harness the power of theater as a tool for community involvement. Collaborating with local theater companies, they create and perform plays that are not only performed in the local languages but also respect and reflect community customs, making the science behind malaria control accessible and relatable. Another innovative tool in their arsenal is the “Mozzie Drive” card game, co-developed with their modeling team, Dr. Ace North and Dr. Katie Willis. This game, which simulates mosquito migrations, mat-ing, and gene drive releases, has been effectively used in events like the Imperial College’s Great Exhibition Road Festival to engage audiences and educate them about gene drive technology in an entertaining and understandable way.

Finally, Target Malaria’s efforts extend to digital media and on-the-ground outreach. They have developed an animated video series in collaboration with Ryan Carter Images and Emerging Ag, which elucidates their strategies and relationships with various stakeholders. This initiative is key in building trust and facilitating informed decisions within local communities. Additionally, their micro-programs have been successful in rural communities, serving as a modern-day equivalent of the traditional town crier, disseminating vital information about their work in malaria control. Collectively, these diverse communication strategies underscore Target Malaria’s commitment to their mission of combating malaria. By adopting this multifaceted approach, they not only advance scientific understanding but also foster support and collaboration in the global fight against malaria.

In the battle against malaria, the role of vaccines is becoming increasingly important. The Malaria Vac-cine Implementation Programme (MVIP) has yielded high-impact results that are pivotal in malaria control efforts. Detailed in a symposium co-chaired by John Bawa of PATH and Dr. Rafiq Okine of WHO, the MVIP has demonstrated the substantial effectiveness of the RTS,S/AS01 malaria vaccine in real-world settings in Ghana, Kenya, and Malawi. Over 46 months, the vaccine reduced child mortality by 13% and severe malaria admissions by 22%, with an average coverage of about 65% for the first three doses.

These findings show that the vaccine’s uptake is high and it integrates well with existing malaria control measures without affecting the use of in-secticide-treated nets, other vaccine uptakes, or health-seeking behaviors. The vaccine’s strong safety profile after more than 6 million doses bolsters its suitability for broader use.

The MVIP’s success emphasizes the need for equitable vaccine delivery, reaching children across different gender and socioeconomic groups. This approach is central to global health initiatives focused on equity and access.

The insights from the MVIP have shaped WHO’s updated recommendations for malaria vaccines, now including both RTS,S and R21/Matrix-M vac-cines. This development marks a significant advancement in the global fight against malaria, offering new tools to combat the disease.

The establishment of the GAVI Malaria Vaccine Programme and support for scale-up, as discussed by Dr. Mary Hamel from WHO, highlight the potential of the malaria vaccine to change the landscape of malaria prevention. With GAVI’s approval for broad vaccine rollout in 18 countries starting in 2024 and plans for vaccine introduction in at least 28 African countries, the future of malaria control is promising. The anticipation of sufficient vaccine supply, including the availability of a second vaccine, R21/Matrix-M, suggests a new era in the global fight against malaria.

The integration of genomic surveillance into malaria control strategies represents a significant advancement in public health. The use of genomic surveillance to track genetic structures and mutations of malaria-causing Plasmodium parasites and mosquito vectors offers a deeper understanding of disease transmission, severity, and treatment response.

The Wellcome Sanger Institute’s Genomic Surveillance Unit, dedicated to malaria, is building integrated malaria molecular surveillance (iMMS) systems in partnership with institutions across multiple countries and regions. This initiative aims to develop comprehensive genomic surveillance platforms within malaria-endemic countries, enabling them to sample, sequence, and analyze data independently.

Standardizing and harmonizing new genomic surveillance protocols across different laboratories presents several challenges, including ensuring reliable internet connections, managing disruptions in lab supply procurement, and maintaining skilled staff. Overcoming these challenges requires collaborative efforts among international partners.

Four out of the six laboratories supported by this project are already operational, generating crucial malaria data. This model of genomic surveillance, synergizing local capabilities with global support, could potentially be replicated in other regions, enhancing the global response to malaria. Such an approach ensures that research institutions control their data and contribute significantly to public health decision-making at local, regional, and global levels.

This ambitious integration of genomic surveillance into malaria control strategies reflects a broader shift toward innovative and interconnected approaches in combating infectious diseases. As the world faces new and evolving health challenges, the role of genomic surveillance will become increasingly vital. Leveraging this technology can keep the global health community one step ahead in the battle against malaria and other infectious diseases, ultimately saving lives and improving public health outcomes worldwide.

In conclusion, the ASTMH Conference in Chicago brought to light the complex and evolving challenges in malaria control. Innovations in vector control, adaptations to mosquito behavior, and advancements in technologies like gene drive and genomic surveillance were key focal points. The success of the Malaria Vaccine Implementation Programme highlighted the potential of vaccines in reducing the burden of malaria. Efforts in effective communication underscore the importance of engaging communities in the fight against this global health threat. Collectively, these developments mark a significant stride in the multifaceted battle against malaria, emphasizing the need for continued innovation, collaboration, and strategic policy-making in public health.