The challenges of bringing malaria innovations to scale

SAN FRANCISCO — How could air capture technology, which is being developed to limit the impacts of increasing levels of atmospheric carbon dioxide, be applied to malaria?

The easiest way for mosquitos to find humans is through the air we exhale, and Nazzy Pakpour, an assistant professor at California State University, East Bay, wondered if there might be a way to mask the CO2 that people emit, making it harder for mosquitos to track them down.

Her team won a global health hackathon at the University of California, San Francisco, last Friday, where they pitched a new idea to develop necklaces made of activated charcoal that could help people who enter areas with high risk of malaria from getting infected and bringing the disease back to low-risk settings.

“I think historically there has been this thought that all people in malaria-endemic places are the same, but it’s not a one-size-fits-all approach, so, just like with an app where you do research on your users, the people who need the product should have the strongest voice,” Pakpour said.

The hackathon, organized jointly by UCSF Global Health Sciences and the Chan Zuckerberg Biohub —  a new medical science research center funded by Facebook CEO Mark Zuckerberg and his wife Priscilla Chan — had teams spend three days together to come up with new approaches and tools to address the problem of outdoor biting mosquitoes in low-resource settings. The transdisciplinary groups brought perspectives not just from malaria and entomology but also technical fields such as engineering, software, and biomedical research, and they came up with a range of new tools to monitor and control mosquitoes that transmit malaria and other diseases including dengue and chikungunya.

“We have good tools for indoor biting mosquitoes,” said Colin Boyle, director of UCSF Global Health Sciences, before introducing the teams. “But with eradication, outdoor biters are a problem.”

Despite high marks from judges for feasibility, innovation, and scalability, the hackathon served as a reminder of some of the barriers in the way of taking new ideas for malaria eradication from the lab to the field.

“This is an interesting time period in the fight because we’re trying to get to scale with proven interventions,” Kenneth Staley, the new Global Malaria Coordinator with the U.S. President’s Malaria Initiative. Speaking to UCSF students and hackathon participants ahead of the pitch competition, he talked about the PMI model, explaining that unlike the Global Fund to Fight AIDS, Tuberculosis and Malaria  — which is purely a financing facility — PMI can also buy commodities and provide technical assistance.

Staley noted how challenging it is to get interventions approved by the World Health Organization, which sets and disseminates global policies on malaria control and elimination, because even after something is prequalified, it has to go through a policy recommendation.

“And when you get to the level of policy recommendation, you get to some of the stickiest issues in global health,” he said.

For example, despite studies proving how the use of insecticide-treated bed nets can reduce the number of people who die, there has been a delay in getting these products to the field.

“We were able to unstick that,” Staley said.

He said PMI, the Global Fund, and the Bill & Melinda Gates Foundation — also a major funder of malaria — worked together to convince WHO to issue more permissive guidelines, which would, for example, open up the options for which bed nets may be procured.

“The question in the malaria community is, where along that risk-seeking continuum should we be?” he said. “One of the most ethically challenging areas for us is how much risk-seeking behavior will we undergo.”

Staley, who used to work in medical technology where he led several efforts aimed at expanding access to medical technology in emerging markets, used a pacemaker as an analogy. The first one would be rushed to market for its life-saving potential, but the 13th might face a higher bar, because with other solutions in place the risk tolerance is different.

The amount of risk that should be taken with regard to malaria has divided the community, with some saying the global health community must be very risk-seeking because so many people are still dying, while others demand a body of evidence as if each innovation were the 13th pacemaker to the market.

At one point, a member of the audience asked what the criteria are for determining what technology is proven.

“This can of worms is what’s holding back a lot of products,” Staley said.

Part of what appealed to the judges about the idea Pakpour and her team pitched was that it would build on Bay Area innovation on carbon dioxide capture and apply it to personal use. She and her team won $2,500 and in-kind support from the Chan Zuckerberg Initiative and CZB to further develop their ideas. As a next step, Pakpour said she plans to do some simple behavior experiments with students, activated charcoal, and mosquitos.

Pakpour said that despite the challenges at scaling innovation, she had seen some progress over her 20 years working with mosquitos, and remains hopeful.

“When I was first getting trained, nobody talked about the social and cultural context in which we were trying to eliminate malaria. It was all focused on the mosquito and the parasite. And that conversation has really shifted, where you don't hear of a single presentation or idea or workshop where that isn’t brought up — that you need the buy-in of communities and you need on the ground support, and it needs to be as sustainable as possible,” she said.