Letter to malaria partners (September 2020)

Dear friends and partners,

My last “Letter to partners”
came to you in December 2019, following the launch of the World malaria report. Since that time, the world has changed in ways we never could have imagined. I hope that you and your loved ones have managed to avoid contracting COVID-19, or
to recover from it rapidly. For those who have lost family members or friends, I extend my deepest condolences.

This letter will focus largely on WHO’s efforts to address the double challenge of malaria & COVID-19. Our work in recent months has been carried out in close collaboration with country-based experts and global partners. We are very grateful
to all of our partners for their ongoing commitment and contributions.

Topics covered in this letter

• Malaria & COVID-19
• Virtual forums
• Improving the way we develop and share policy guidance
• New policy guidance app
• Artemisinin resistance in Rwanda

Malaria & COVID-19

As COVID-19 began its rapid spread earlier this year from China to Italy, and beyond, alarm bells began ringing across the malaria community. After taking such a devastating toll on countries with robust health systems, how would malaria-endemic countries
in Africa prevail? Among colleagues at WHO, there was deep concern that the coronavirus had the potential to upend years – perhaps decades – of progress in malaria control.

In March, before COVID-19 had secured a strong footing in Africa, WHO established a cross-partner mechanism aimed at mitigating the impact of the pandemic in malaria-affected areas. Since that time, leaders and experts from more than 30 partner organizations
have been lending their expertise across 7 workstreams focused on a range of issues – from disruptions in the supply of key malaria commodities to surveillance and clinical drug trials. 

Our first order of business was to issue a clear statement calling for the continuity of malaria services. We were troubled by reports that some countries in sub-Saharan Africa
had suspended mass insecticide-treated net campaigns, the mainstay of malaria prevention efforts in the region for nearly 2 decades. Our statement, published on 26 March, underscored the critical importance of ensuring the safety of communities and
frontline health workers.

Several weeks later, WHO and partners delivered 2 key documents that have helped shape national malaria responses during the pandemic:

• New guidance describes how to safely maintain core malaria services in the context of COVID-19. It makes clear that countries need not choose between either protecting their populations from COVID-19 or malaria; they can –and should
  – do both. This malaria-specific guidance is aligned with broader WHO guidance on maintaining essential services in COVID-19 settings. It also complements guidance from
  WHO, UNICEF and IFRC on the role of community-based health care.
• A modelling analysis,
  published just ahead of World Malaria Day, reinforces our urgent call for sustaining malaria services. Under the worst-case scenario, we predicted a doubling in deaths in sub-Saharan Africa in 2020 alone if access to net campaigns and antimalarial
  treatment was severely curtailed during the pandemic.

We have been very encouraged to see net campaigns move forward in many countries across Africa. Benin, the Democratic Republic of the Congo, Sierra Leone and Chad paved the way this spring, and many others have followed in their footsteps. In line with
WHO guidance, all countries have adapted their distribution strategies to ensure households receive the nets as quickly and safely as possible.

However, we have been unable to effectively track access to, or use of, other preventive approaches, such as IPTp for pregnant women, an intervention typically delivered through antenatal care facilities. The full impact of the pandemic on malaria diagnosis
and treatment – which can normally be accessed through primary health care facilities – is also unknown. Many of the reports we have received are incomplete or anecdotal.

Paradoxically, in some areas there are reports of reductions in malaria, which probably reflects the fact that fewer people are seeking care at health facilities; if a person with a malarial fever does not seek care, he or she will not be diagnosed, treated
or reported. We expect a clearer picture to emerge as more data become available.

We will continue to keep you updated on our ongoing efforts to tackle malaria & COVID-19. Our Q&A provides additional background and is updated periodically. 

Virtual forums

Later this week, WHO and the RBM Partnership to End Malaria will co-host live, interactive forums on 2 consecutive days under the theme: “Responding to the double challenge of malaria & COVID-19.” On day 1, we will hear from country-based experts
about the challenges they are facing on the frontlines of the response to these urgent health threats. Their shared reflections will inform discussions on day 2 with global health leaders, including our WHO Director-General, among others.

Discussions with be moderated in English, with simultaneous translation in French and Spanish. We encourage you to register in advance; an agenda and registration details can be found here. 

Improving the way we develop and share policy guidance

In 2018, as you may recall, the Global Malaria Programme (GMP) undertook an extensive review of our policy-making processes for malaria. Following the recommendations that came out of this exercise, our malaria policy pathway is now structured around 3 high-level steps: 

• better anticipate
• develop policy
• optimize uptake

In order to better anticipate unmet public health needs (Step 1), GMP solicited suggestions in 2019, including via an online consultation, for topics requiring new or updated malaria policy recommendations. Based on the feedback received, we are forming individual guideline development groups (GDGs) for each of the technical areas identified: chemoprevention, vector control, elimination, treatment, diagnosis, Plasmodium vivax, and anaemia.

To enhance the transparency of our processes, GMP will publish the names and brief biographies of individuals who are being considered for participation in each GDG. Everyone is welcome to comment on any perceived conflicts of interest.

We are currently inviting comments, through 8 September, on proposed members of a GDG on malaria elimination. For details, please visit this link.  If you would like to receive regular updates on the GDGs – including alerts about other upcoming “calls for comments” – send us an email at: [email protected].

New policy guidance app

Step 3 in our new policy pathway calls for optimizing uptake of WHO’s malaria policy guidance, particularly in endemic countries. To that end, I am very pleased to share a new app which brings together all WHO policy documents on malaria – guidelines, recommendations, operational manuals and other technical documents – in one easy-to-navigate resource.

Download the app for iOS devices | Download the app for Android devices

The app complements the Compendium of WHO malaria guidance, published in April 2018, and a dedicated policy guidance section on the WHO website.

Artemisinin resistance in Rwanda

As you may have seen, Nature Medicine recently published an article confirming the emergence in Rwanda of parasites with mutations associated with artemisinin partial resistance. The study found, at the same time, that artemisinin-based combination therapy (ACT) continues to be an effective treatment for malaria.

This article was co-authored by WHO and is based on data generated by WHO surveillance systems. Importantly, the parasites emerged independently in Rwanda and did not spread directly from the Greater Mekong Subregion, as some had predicted. 

Unfortunately, some news articles have misrepresented the key findings and implications of the study. Together with our malaria partners, we have been working to reinforce the message that ACTs – at this point in time – continue to be an effective treatment for malaria in all settings around the world, including Rwanda. We encourage you to read an information note on this issue developed by Medicines for Malaria Venture as well as our WHO Q&A.