We must move away from a one-size-fits all approach to malaria control

Exactly one month before World Malaria Day, on March 25, I traveled to several villages in Uganda as part of a team handing out bed nets that would help prevent Ugandan citizens from contracting malaria. Throughout the visit, my thoughts wavered between optimism and apprehension.

On the positive side, malaria is one of the greatest global health success stories. Since 2000, 6.2 million lives have been saved and there has been a 60% reduction in malaria-related deaths along with a 37% reduction in new cases. In Africa, long-lasting insecticidal bed nets (LLINs) have been credited with nearly 70% of that reduction.

But, despite tremendous progress, much work still remains. In 2015, there were some 212 million malaria cases and an estimated 429,000 malaria deaths. And, while half of Africa sleeps under treated mosquito bed nets (compared to 2% in 2000), mosquitoes are becoming resistant to the only class of insecticide currently approved for use on bed nets. Several regions in Africa are experiencing a resurgence of malaria and experts believe that insecticide resistance has the potential to derail gains made so far.

Malaria is a huge problem in Uganda. The country has the sixth highest number of annual deaths from malaria in Africa and some of the highest reported malaria transmission rates in the world. In 2013/2014, the government distributed more than 20 million insecticide treated nets throughout the country. Yet, despite the increased coverage and protection against malaria, northern Uganda has since experienced a six fold increase in malaria cases after the withdrawal of indoor residual spraying, even in the presence of high bed net coverage. As a result, when planning the 2017 national bed net distribution campaign, Uganda recognized the need for a more strategic, tailored approach to malaria control.

The government initiated a rigorous year-long evaluation process to determine the most appropriate LLINs to procure and distribute. It tasked a team of experts to analyze the existing data and, based on their findings, decided to deviate from the standard one-size-fits-all approach. Instead, Uganda chose to include an alternative net, called a PBO net because it uses a synergist (piperonyl butoxide or PBO) that enhances the effectiveness of the insecticide approved for use in bed nets.

About one-fifth of the 24 million nets being distributed in Uganda’s national campaign are PBO nets and they are being deployed in districts where insecticide resistance is documented. Since this is the first time the PBO nets are being distributed at scale, the government has initiated a monitoring component that will generate operational data to determine the effectiveness of the PBO nets in resistance settings.

I spoke to many villagers throughout the weekend I was in Uganda. They thanked me for the nets, and some of them shared memories about loved ones who had lost their lives to malaria. Several said they were worried that their nets weren’t working because they were finding more mosquitoes inside the nets when they woke up in the morning.

I knew that the PBO nets we were giving them would provide a more appropriate solution, and I was thankful that the government had undertaken such an intensive evaluation which showed that different communities with varying levels of insecticide resistance require different solutions. The reality that malaria vector control needs to be tailored to local conditions was recently echoed by the World Health Organization when it noted that “There is no ‘one size fits all’ strategy” in its 2017 Framework for malaria elimination report.

We absolutely cannot let the gains we’ve made in malaria control slip away. The global malaria community must view Uganda as a shining example of forward-thinking leadership, data-driven decision-making and a willingness to invest in new technologies. Other countries must take a serious look at what the scientific evidence tells them, and be willing to scale up new technologies that help prevent people in their communities from contracting malaria. More companies like mine must continue to innovate and develop new technologies to maintain the progress in malaria control as we strive, ultimately, for elimination.

Malaria is a preventable disease which means that even one death caused by it is unacceptable. We must keep up our commitment to fight malaria with the most sustainable and smartest ways forward. Thanks to the government of Uganda for leading the way.

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