Q&A: Partnerships and pesticides — stepping up the fight against malaria

A young boy in Kenya is protected from malaria under a PermaNet 3.0. Photo by: Vestergaard

More effective tools that can be rolled out rapidly and equitably, combined with strategic partnerships are key to tackling malaria, according to Michael Joos, CEO at Vestergaard, a social, for-profit, enterprise specializing in science-based innovations to address global health challenges like malaria, food security, guinea worm disease, and sleeping sickness.

In 2019, cases of malaria stood at over 229 million — most of them children under five — killing over 400,000 people, according to the World Health Organization. A recent survey shows that COVID-19 has led to a decrease in malaria diagnosis and malaria treatment, possibly erasing any previous gains.

To avoid further back-sliding on eradication efforts, more effective next generation bed nets, such as Vestergaard’s PermaNet 3.0 mosquito net, need to be rolled out at a faster pace, Joos said.

“The new class of pyrethroid-PBO bed nets [bed nets containing the synergist piperonyl butoxide] designed to kill insecticide resistant mosquitoes took more than 10 years to bring to [the] market,” Joos said, adding that there is a need to launch new generations of bednets faster than mosquitoes can mutate and develop resistance. “A full review of the regulatory path to market where a faster adoption and better in-field evaluation of bed net performance would be helpful."

Strategic partnerships will be key to doing that, Joos said, adding that the public health community needs to see suppliers as more than just transactional partners. This would enable the private sector to make longer-term capital resource allocation decisions that would aid innovation and avoid production capacity bottlenecks.

“There’s an opportunity to have much more strategic engagement and figure out ways and means that businesses can help to further the fight against malaria. The pandemic has shown that this is possible – the same could and should be done for malaria.”

Speaking to Devex, Joos explained how Vestergaard is working to tackle malaria, the lessons it has learned in doing so, and why innovation is critical to the fight against malaria.

This conversation has been edited for length and clarity.

Why is there a need for renewed attention and efforts in tackling malaria?

The death rate is one thing, but malaria also places a huge burden on health care systems. The economic impact on countries is massive because it takes out a big portion of the working population either being sick or looking after sick loved ones.

“Within a year, we have managed to bring the most effective [COVID-19] vaccines to [the] market, showing us that if we really want to eradicate malaria, we can.”

—  Michael Joos, CEO, Vestergaard

There have been considerable successes. Since the millennium, malaria mortality rates have reduced by 60% and 21 countries have eliminated the disease … but in the past few years, the reduction in malaria deaths and cases has stalled and flattened out. There are a number of reasons for that, including the high population growth, especially in the high burden areas of sub-Saharan Africa, the rise of insecticide resistance, and drug resistance to antimalarial treatments.

At the start of the pandemic, WHO raised the alarm and said that we couldn't afford to have any disruptions in terms of the delivery of prevention and treatment tools. Luckily, some of the worst case scenarios didn't pan out, but nevertheless the Global Fund to Fight AIDS, Tuberculosis, and Malaria has recently issued a report that showed that access to malaria treatment and diagnosis has reduced quite significantly in Africa. Alarmingly, [over] 20% of facilities surveyed were completely out of the antimalarial medicine dosage for children under five-years of age.

Talk us through the value of a simple intervention, such as a bed net, in tackling malaria.

Insecticide-treated bed nets, [or ITNs] — such as those we manufacture — have always been the backbone of any malaria program upon which additional interventions are layered. During the pandemic, the humble bed net is quite literally holding the fort in many settings. It’s an extremely sophisticated and cost-effective device that offers two fundamental levels of protection. On the one hand, it's a physical barrier for the sleeper so that the mosquito that transfers the parasite from one person to another is unable to go through. The second level of protection, that is probably less well understood, is the insecticide treatment of the net, which is there to kill and reduce the population of mosquitoes. The insecticide is coated or incorporated into the fibers of the bed nets and remains bioavailable for an estimated three years. The second part only works if you have a mass deployment of these nets throughout the community.

ITNs are a fairly low-cost intervention that is long-lasting in duration. A few dollars can buy you two to three years of protection, which is why it has become the backbone of malaria control programs.

How has Vestergaard innovated around the bed net?

The initial bed nets handed out were bed nets that you would dip every few months into an insecticide solution. That wasn't a great way to do things, quite frankly, and an unnecessary exposure of people to powerful insecticides. And so Vestergaard, with others, improved on the first generation of insecticide-treated bed nets to eliminate the constant need to retreat the bed net. PermaNet 2.0, a long-lasting insecticidal net, was our first innovation.

In the past 10 years, the biggest problem that we have identified is insecticide resistance. Vestergaard has put the problem of insecticide resistance firmly on the map for the malaria community, by creating a tool called IR MAPPER, where all the research around insecticide resistance is geographically mapped. We also established the Vestergaard-Noguchi Memorial Institute of Medical Research at the University of Ghana, to further the science and to accelerate research and development efforts to tackle insecticide resistance.

These R&D efforts led to the innovation of the first pyrethroid-PBO net, PermaNet 3.0, which incorporates a synergistic substance to improve the killing potency of the insecticide. A new combination of active ingredients has essentially increased the killing power against mosquitoes that have mutated and become resistant to pyrethroid insecticides. Pyrethroid-PBO nets have now become the standard of care in high-burden countries.

What lessons have you learned from your work in this area?

Joos on malaria and food security:

“Once we knew how to put insecticides on bed nets, the obvious next place was to do the same on food storage bags to increase food security for small-holder farmers. Such technology has huge potential in terms of preventing post-harvest loss while allowing storage and easier transportation of food produce.

Africa has more than half of the world’s arable land, a crop yield growth potential of 10 times to reach equivalence with higher-income nations, and over 60% of the population working in the sector. Investments in agriculture in Africa present a huge business opportunity but can also lift people out of poverty by getting better yields and income to the farmer. If you pull people out of poverty, you unleash a cascade of positive impacts and make progress on virtually all of the sustainable development goals.”

The low-hanging fruits have been harvested and so any innovation that comes along now is, by an order of magnitude, more complex. Complexity of screening of the correct combination of insecticides or active ingredients is a challenge. We need to find new classes of active ingredients that can be used on bed nets. Complexity of the polymer science element of how to attach an active ingredient onto a bed net in such a way that it's safe for the user and that it provides continuous mosquito killing efficacy over a long period of time. And then, complexity of manufacturing must also be considered. We also need to make sure that we deliver such technologies at scale so that we can have an at-scale cost structure.

Following World Malaria Day, do you have a call to action for the global health community?

First, the COVID-19 pandemic has taught us that it is possible to innovate and deploy rapidly the most effective tools to address killer diseases. Within a year, we have managed to bring the most effective vaccines to [the] market, showing us that if we really want to eradicate malaria, we can. Second, as we continue the fight to control the COVID-19 pandemic, we must stay focused on the fight to eliminate malaria. Precisely because we have demonstrated the speed and can-do attitude of global partnerships, we must use this opportunity to step up the fight on malaria.

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