Q&A: MESA chair talks next steps in the fight against malaria

BARCELONA — The new research agenda for malaria elimination and eradication — malERA Refresh — was published late last week. This special collection of papers, coordinated by the Malaria Eradication Scientific Alliance, or MESA, and published in PLOS Medicine, will define the global malaria R&D agenda; inform the World Health Organization's evidence-based guidelines and policies; and guide funding. The agenda, which stresses the need to develop new tools and combine them in a context-specific manner, is the result of consultations with over 180 scientists, malaria program leaders, and policymakers from around the world. Its production was overseen by a leadership group including Pedro Alonso, director of WHO's Global Malaria Programme; as well as experts from Harvard, the Swiss Tropical and Public Health Institute, and MESA, with headquarters at the Barcelona Institute for Global Health. It notes that the progress in R&D in malaria since 2011 has been matched by challenges such as the expansion of drug and insecticide resistance and knowledge gaps, particularly with regard to low disease transmission settings and ways to prevent disease reintroduction. Solutions to these challenges require iterative, transformative, and integrated innovation, it says, including improving existing tools and developing new tools to reduce parasite transmission. The 2017 WHO World Malaria Report, also released last week, warned that progress in fighting the disease has stalled. In 2016, there were an estimated 216 million cases of malaria globally, 5 million more than in 2015, and deaths plateaued at 445,000. In terms of funding, the $2.7 billion invested last year represent less than half of what is required by the Global Technical Strategy for Malaria. Devex caught up with MESA chair Regina Rabinovich — who also serves as ExxonMobil Malaria Scholar in Residence at Harvard University — to discuss innovation priorities in the fight against malaria, as well as funding and next steps in pushing the agenda forward. The conversation has been edited for length and clarity. The first malaria research agenda was launched in 2011. Why refresh it now? We started off asking that same question. We did a literature review and found that all four parts of the landscape — what has progressed, and what has stalled; what the world was thinking was actually going to work; and what were the problems we were facing — had continued to change very rapidly because of investments in malaria. MalERA stresses the need for cross-cutting solutions in areas such as implementation science and surveillance. Which priorities would you highlight in terms of innovation? In malaria, we have to simultaneously deal with various species of mosquito and parasite, and with humans, which are the active reservoir. This heterogeneity means that, whether you are conducting research or working in the field, you need to figure out how to combine and adapt the existing or incoming tools and strategies for best impact. That is, you need to figure out how to tie diagnostics, drugs, surveillance and reporting systems together to more closely respond to local contexts. We have to get smarter and better at delivering both vector control and treatment. We also need to improve the drugs and vector-control tools that we already use, as well as transformative innovations to reduce the parasite’s capacity to transmit. These range from novel approaches such as genetically-engineered mosquitoes that are unable able to carry the parasite, to new ways of using old tools that have been available for decades. Ivermectin, for example, is a drug used to kill worms causing diseases such as lymphatic filariasis. As it turns out, it also kills the mosquitoes that bite whomever is taking it. All of a sudden, you are not trying to kill all mosquitoes, but only the ones that bite humans. That is a totally different way of thinking about how to deal with them. Pushing innovation forward and scaling it up will take resources. What is the estimated investment required to fund this research agenda? We have not costed it out and there are reasons for that. We know there are areas that are hugely underfunded: research connected to the malaria-causing parasite P.Vivax is slowly coming up; operational research to be able to figure out how to do it better [in the field] is a little haphazardly funded, which we are tracking right now; and vector tool development — everything that is geared towards the mosquito — has much less funding than it needs to have, particularly in terms of innovative approaches. Partly because different groups fund different parts of the problem, it is not about giving a single figure. Instead, it is about focusing on specific areas and saying “we are not putting enough effort in here” or ‘we need to do a much better job at figuring out what to do in the field.” According to malERA Refresh, “a diverse landscape of funders is needed to prioritize research objectives according to their strategic plans and stakeholders’ needs.” What is your take on the concern that funders end up directing the research agenda? There are at least two ways of approaching funding. Polio, for example, has a research fund. The research committee gets together and says “these are the things we think need to be done.” Then, they go to one pool of funders and they figure out who will fund what. In malaria, with about 200 million cases every year, we are nowhere near the end stage. Different funders fund different kinds of things, and that is not only their prerogative, but their expertise. For example, Wellcome Trust has a fantastic genomic center; the Bill & Melinda Gates Foundation has put money into product development in a variety of different ways; and DFID funds operational research. So, in administering effects, we are not advocating for having a central fund — because that would mean even more direction and less innovation — but actually pulling in more funders. UNITAID, for instance, is a relatively new entry into the malaria space, and one way it adds value is by focusing on some of the vector control issues that IVCC is not funding. It is precisely because expertise in assessment and funding of the problems differ that malaria benefits from a diverse set of funders. There is much buzz around innovative finance mechanisms. Could they play a role in R&D for the elimination of malaria? Everyone would like to see that work for R&D. It is worth pursuing, and everybody would like money to come out of somewhere that is not their pocket. Eventually, though, countries need to commit to their people and they are the biggest funders. I do not see a fast-out solution. I think it is up to us to advocate; to continue to point at areas that need additional resources, and to track [progress], and this is partially what we were doing with malERA. Now that the research agenda has been published, what is the way forward from here? Planning briefings with major funders. Treatment gets more resources because, among other things, you have got the anxiety of the patient in your hands. Prevention is harder to get funded, including vaccines and vector research. This is why reports like malERA identify areas that are promising but have gaps. The papers try to capture a sense of both excitement and urgency. There are things that can be done, science that can be applied. At the same time, [the fight against] malaria has stalled, and investments in science, product development and improvements [of tools and strategies] are going to be critical to move forward. Read more Devex coverage on malaria eradication.