World Malaria Report 2022: The Boat Did Not Tip, But the Storm Is Not Over

[This text has been written by Murchana Roychoudhury, communications officer at ISGlobal, and Regina Rabinovich, director of the Malaria Elimination Initiative at ISGlobal]

The World Malaria Report 2022, produced by the World Health Organization (WHO), gave us much-needed reassurance – the worst has been averted. National malaria programs and their partners “held the line” during the COVID-19 pandemic, ensuring no further increase in the number of malaria deaths in 2021. Yet, the combination of rising biological threats and global economic and humanitarian crises risks point to the urgent need for new financing of health system innovations and new ways to use existing as well as new tools to combat emerging threats. 

Bouncing back from the initial shock of the pandemic

An estimated 247 million cases and 619,000 deaths in the 2022 report was an important reality check – we have a long way to go to meet the 2030 malaria goals, as well as a sigh of relief – the increase in the loss of lives to malaria, which resulted from the COVID-19 pandemic in 2020, had not progressed. Holding the line could not have been achieved without the perseverance of the malaria community, as many worked to minimize disruptions in prevention, treatment, and diagnosis services in the middle of the global health crisis.

Source: World Malaria Report, 2022

Insecticide-treated nets (ITNs), the primary vector control tool used in most endemic areas, reached 75% of planned targets, a level similar to the pre-pandemic year of 2019, and the same happened with the number of pregnant women receiving intermittent preventive treatment of malaria in pregnancy (IPTp). Some interventions like seasonal malaria chemoprevention (SMC) even reached new horizons, treating nearly 45 million children in 2021, an increase of 11.6 million as compared to 2020. Moreover, global supply chain challenges were overcome to ensure the availability of rapid diagnostic tests and artemisinin-based combination therapies.

But the fact that the situation has not worsened when compared to 2020 is far from achieving the global goals: thousands of lives are still lost to this disease. Effective tools are simply not reaching all that need them, allowing mosquitoes to transmit malaria parasites and preventing many that get infected to be properly treated.

In addition to such coverage gaps of existing malaria interventions, novel threats have been identified which may jeopardise the huge gains made so far. As highlighted by this year’s World Malaria Report, malaria vectors and parasites are rapidly evolving and current tools are starting to prove inadequate in many contexts. These biological threats challenge effective malaria diagnosis, vector control, and treatment:

• Rapid diagnostic tests, the cornerstone of malaria diagnosis in most endemic countries, which enable the currently recommended ‘test and treat’ strategies, increasingly lead to ‘false negative’ test results as a result of the deletion of the protein antigen targetted by RDTs.
• Insecticide-treated nets, which have played a central role in malaria transmission reduction since the 2000s, are now proving to be less effective due to widespread resistance to pyrethroids – the primary insecticide class currently used in ITNs. The good news is that new bednets to overcome resistance are being introduced.
• Artemisinin-based combination therapies are recommended by the WHO as first- and second-line treatments for uncomplicated Plasmodium falciparum Though these medicines continue to be efficacious, warning signals have emerged from Africa, suggesting the emergence of ‘partial resistance’ to artemisinin in three countries.
• Anopheles stephensi, once considered the ‘Asian malaria vector,’ has now made its way to Africa. Given that this invasive species is resistant to several classes of insecticides, bites both indoors and outdoors, and thrives in urban settings, it could significantly increase transmission where it becomes widespread.

These biological threats are augmented by a global context characterized by economic, humanitarian, and climate crises, all of which can directly affect malaria. The WHO has been updating the Malaria Threats Map, to reflect these threats so that countries are informed of the latest data.

These biological threats are augmented by a global context characterized by economic, humanitarian, and climate crises, all of which can directly affect malaria.

ISGlobal has contributed to global efforts, engaging in the development of genetic surveillance systems to detect HRP2 deletions and drug-resistant parasites in malaria-endemic countries. Through the MESA Alliance, it has also contributed to mapping ongoing research and surveillance efforts on emerging biological threats and has collaborated with WHO in raising awareness on pressing topics, including An. stephensi invasion and urban malaria.

The need for innovation in R&D including implementation science

In addition to keeping an eye on these novel threats and developing technical guidance to overcome them, new tools and strategies are urgently needed. Between 2000 and 2021, an estimated 2 billion malaria cases and 11.7 million malaria deaths were averted, an achievement largely owed to lifesaving innovations added to the malaria toolbox in the last two decades. But these current tools will not take us to the finish line. Fortunately, the R&D pipeline highlighted in this year’s World Malaria Report provides rays of hope in dire times.

New nets are on the horizon with new insecticide combinations. To keep up with the changing biting patterns of mosquitoes, scientists are exploring new approaches like attractive targeted sugar bait to prevent outdoor transmission and the repurposing of drugs that kill mosquitoes that feed on the blood of populations that have taken endectocides at a population level. ISGlobal is actively working in this latter area through the BOHEMIA project, which evaluates the impact of mass drug administration of ivermectin to humans and livestock in Mozambique and Kenya. New candidates for vaccines are approaching advanced phases of clinical trials. Options like triple artemisinin-based combination therapies and next-generation antimalarials are being explored in the area of treatments. While this paints an optimistic picture of the future, the report also underlines that 2021 was the third consecutive year of declining malaria R&D funding.

While this paints an optimistic picture of the future, the report also underlines that 2021 was the third consecutive year of declining malaria R&D funding.

A critical point in the R&D field is the need for strengthening Operational Research and Implementation Science to enhance the impact of antimalarial tools that we already have. We need to generate evidence on how to improve the quality and coverage of health interventions and work systematically to incorporate such evidence into policies and practices. ISGlobal has extensively worked in this area, including, among other examples, developing and evaluating innovative delivery strategies for IPTp through community health workers, which has proven to be a useful complementary approach.

Protecting the gains and beyond

We cannot underestimate the malaria problem. We might have averted the worst outcomes predicted during the pandemic, but we continue to confront major challenges. To preserve the hard-won gains of the last two decades against the disease, it is time to exploit all available resources and explore new avenues of support.

To preserve the hard-won gains of the last two decades against the disease, it is time to exploit all available resources and explore new avenues of support.

Investing in resilient primary health systems and integrating malaria services with routine health services is one such avenue. Focusing on reaching populations that are persistently left behind by fragile health systems is a must.

Malaria elimination is not a dream, but a long-term resolve that requires unwavering commitment and a coordinated effort from all stakeholders. This year’s report is a strong call to action to mobilize leaders, communities, resources, and health systems to reach the end goal of zero malaria.