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Malaria Elimination Proof Of Concept?

Cabo Verde hasn't had a case of malaria in three years. It once had the deadly disease on all ten of its islands.

We live in a time when there is a lot of tough news related to our struggle against poverty and poverty-enhanced disease. By some estimates, nearly 7 million people have died from COVID-19, and the virus's economic costs have been catastrophic for families, communities, and countries the world over.

However, there is renewed hope for progress in tackling one of the world's greatest killers: malaria. Caused by more than 100 types of parasites, malaria enters the body through the bite of the female Anopheles mosquito and contaminates the bloodstream. While the US successfully eliminated the disease as a public health threat in 1951, half the world remains at risk of infection according to Malaria No More, a global organization that mobilizes political commitments and funding for malaria eradication.

This January, Cabo Verde joined the ranks of 43 nations and one territory certified as malaria-free by the World Health Organization (WHO)—a remarkable achievement highlighted by Secretary of State Antony Blinken during his recent trip to the country's capital of Praia. Cabo Verde's malaria-free status is especially important in a country where tourism accounts for nearly a quarter of its GDP. 

Thanks to the US President's Malaria Initiative, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and dedicated health leadership in participating countries over the last two decades, the world has made substantial progress in reducing the disease's spread and associated deaths. However, the COVID-19 pandemic saw momentum against the disease reduced (and in some places even reversed) for a variety of reasons. 

Cabo Verde's success story serves as a reminder of what can be achieved if global health leaders refocus their efforts on eradicating malaria once again. Taking on the malaria scourge requires a multi-pronged approach: carefully investigating, diagnosing, and counting malaria cases; providing ill individuals with free, effective, and early treatment; and preventing new cases by administering medicines, controlling mosquito breeding areas, and providing insecticide-treated mosquito nets. 

To be sure, Cabo Verde's path to eliminating malaria had its difficult moments. In 2017, the country reported 184 cases, marking its worst outbreak in more than 20 years. But Cabo Verde made the right investments. When it achieved independence less than 50 years ago, it had only 13 doctors. Today, 80% of its citizens live within 30 minutes of a healthcare facility.

So why is any of this newsworthy and important? Despite great strides, malaria continues to claim approximately 600,000 lives each year—and 95% of these deaths occur in Africa. The 2023 World malaria report found that just four countries make up nearly half of the world's malaria cases: Nigeria, the Democratic Republic of the Congo, Uganda, and Mozambique. And even more tragically, the WHO reports that 80% of malaria deaths in the region are children under the age of five. 

Even for those who survive their bout with the disease, malaria has severe long-term costs and consequences. Sick children are unable to attend school and fall behind on their lessons. In fact, malaria keeps kids out of school more than any other disease. Sick adults are unable to work, straining family incomes and limiting national economic growth. While Malaria No More estimates that $12 billion is lost as a direct result of malaria infections, the true cost of lost growth potential is immeasurable. 

Measures to prevent malaria's spread have saved many millions of lives, and new vaccine developments offer renewed hope for a malaria-free future. Cameroon is currently rolling out the world's first malaria vaccine—RTS,S, or Mosquirix—following successful trials in Ghana, Kenya, and Malawi. As of November 2023, more than 2 million children had received a vaccination, leading to a 13% decrease in early childhood deaths across the three countries. Another 17 nations are waiting in the wings for their own vaccine rollout. And a second vaccine to help keep up with demand, R21/Matrix-M, is undergoing clinical trials.

Cabo Verde may soon have company with its malaria-free status. Sao Tome and Principe, as well as the Comoros, reported no malaria deaths for the first time in 2022. Botswana, Eritrea, and Eswatini have each reported less than 10 malaria deaths. And while it is difficult to know the true impact of malaria treatments and preventative measures, the WHO calculates that 2.1 billion cases of malaria were averted globally between 2000 to 2022. 

It's true that Cabo Verde is a small archipelago—and São Tomé and Principe, along with the Comoros, are also small nations. Their makeup and geography offer advantages in taking on diseases like malaria. Importantly, they also offer proof of concept. They show that with focus, leadership, tools, and discipline, we can defeat diseases that have stolen lives as far back as we can measure—and they offer hope.

This blog was researched and drafted with the assistance of Katherine Schauer. 

Deadly Diseases

The female Anopheles mosquito may well be the most dangerous creature on Earth. When she lands on human skin, she sucks up blood through her needle-shaped mouth and injects saliva into the wound. If this saliva contains Plasmodia parasites, the victims will soon suffer severe fever, violent shivering, and profuse sweating — the telltale symptoms of malaria.

"Malaria" is a misnomer. Drawn from the Italian mala aria, or "bad air," the name reflects the historical belief that the disease is caused by miasmas, or noxious exhalations from rotting matter or stagnant water. In 1889, a tiny parasite was revealed as the disease-causing agent, and eight years later, the mosquito was identified as the parasite-carrying agent.

When a mosquito carrying malaria bites her victim, she injects parasites into the bloodstream, where they migrate to the liver and other organs and incubate. A malaria victim may show no symptoms for weeks or months during this incubation. Then the parasites return to the bloodstream and invade the red blood cells. Rapid multiplication of the parasites ruptures the red cells, releasing more parasites into the bloodstream and causing the characteristic symptoms. If the person does not receive prompt and effective drug therapy, damage may occur to the brain and other organs, sometimes leading to death.

Malaria is largely a geographical disease, endemic to tropical climates in Africa, Asia, and South America. An estimated 350 million to 500 million people worldwide are infected with malaria each year; of the more than one million who die, two-thirds are children. An African child under 5 suffers on average six bouts of the recurring illness each year.

In the United States, malaria was historically a problem in the southeastern states. Begun in 1947, the National Malaria Eradication Program (the precursor of the Centers for Disease Control, or CDC) applied the insecticide DDT to the interior surfaces of rural homes and entire properties where malaria was reportedly prevalent. About 4.6 million houses were sprayed, and five years later, malaria was considered eliminated in the United States.

A remarkable man named Fred Soper first took on malaria in Brazil in the 1930s. With the passion and determination of a field general directing an army, Soper eliminated the Anopheles gambiae mosquito from the country within a decade, stopping a deadly outbreak in its path. His success raised hopes that malaria could be eliminated worldwide. By 1948, 55 nations had signed up for the Global Malaria Eradication Program Soper would go on to lead.

With DDT as their tool, Soper's mosquito warriors were successful in sharply curtailing malaria or eliminating it entirely from nearly 40 countries, including Taiwan, many Caribbean nations, the Balkans, and parts of North Africa. But just as they seemed to be on the brink of victory, their luck ran out. First, mosquitoes began to develop resistance to DDT, and then, in 1962, Rachel Carson's Silent Spring identified the harmful effects of DDT on ecosystems. The chemical was subsequently banned in the United States. While this action benefited the environment, it hurt Soper and his team's international efforts to combat malaria, in which only a small amount of DDT was used indoors. To this day, researchers continue to look for a chemical comparable to DDT in its mosquito-killing effectiveness.

Despite decades of research work, a successful vaccine for malaria remains elusive. Scientists hope that the genetic decoding of the malaria parasite may offer helpful points of intervention for interrupting its life cycle. Meanwhile, several current research efforts seem promising, largely bolstered by the Bill & Melinda Gates Foundation (The Bill & Melinda Gates Foundation is a funder of the Rx for Survival project).

People residing in non-malaria-endemic areas are normally safe in their home countries, although a few cases are reported each year of "airport malaria," in which a mosquito, hitching a ride on an aircraft, causes disease. Travelers to malarial areas have a high risk of catching a serious infection because they lack the natural immunity that provides local residents some protection.

Tourists can take an antimalarial drug as an effective preventative. (If taken for a long time, some of these drugs have long-term side effects, and are therefore not recommended for residents of malaria-endemic regions). Doctors may prescribe a course of medication for travelers that covers the immediate time before, during, and after a visit to a malaria area. Several medications, including doxycycline, atovaquone/proguanil, mefloquine, and primaquine, have proven effective.

But malaria is one of nature's most resilient killers, and the Plasmodium parasite is becoming resistant to these older medications. A promising new drug, artemisinin, has been synthesized from a plant used as a treatment in China for centuries. Demand for artemisinin currently far outstrips supply, and costs of the treatment remain beyond the reach of many malaria victims.

About 99 percent of mosquitoes carrying the malarial parasite are night biters, so for travelers and native populations alike, netting treated with insecticide for sleeping areas is crucial. In the absence of an effective mosquito-elimination method, netting can prevent many of the one million malaria deaths of children under 5 each year, and save many adults from unnecessary illness and death as well.

Return to Deadly Diseases

A National Guard Member Was Told He Likely Had A Virus. He Actually Had Malaria.

Stationed near the Texas-Mexico border as part of the National Guard, Christopher Shingler first noticed a fever, trouble eating and vomiting in May.

Medics gave the 21-year-old tests for Covid-19, and at a hospital the Brazoria County resident was told he likely had a viral infection.

In early June, after symptoms persisted, tests at a different hospital made it official: Shingler had malaria.

The disease, transmitted by mosquitoes, sickens more than 200 million people annually around the world and kills hundreds of thousands. Shingler is one of handful of people in the U.S. Recently diagnosed with malaria without having traveled recently.

"I would wake up really early in the morning and I would start shaking," Shingler said. A high fever would follow and lead to vomiting.

"It was a lot of just trying my best to make myself eat something, as small as I could, which usually I was unsuccessful, or trying to drink water, which, again, I was unsuccessful," Shingler said.

Shingler's out of the hospital now and no longer nauseous. He said he lost around 15 pounds.

He was stationed on the Rio Grande River in Brownsville for most of May, working mostly at night, he said, and first felt sick on May 20.

Shingler does not know how he got malaria or from where. He said the Centers for Disease Control and Prevention has been in contact with him as officials try and find the source.

"We were getting torn up by mosquitoes, chiggers, whatever you can think of, you can name," Shingler said. "We were getting torn up the entire time we were out there, especially that first night."

But he is not aware of anyone else from his unit who felt sick.

The CDC this week issued a health alert about five cases of malaria acquired within the U.S. Over the last two months, meaning they weren't linked to international travel.

The cases — four in Florida and one in Texas — are the first locally acquired in the U.S. In 20 years. The CDC said the risk throughout the country remains extremely low.

Malaria cases in the U.S. Are more commonly found among people who have traveled outside the country.

The disease is most common in African countries, according to the World Health Organization. In 2021, there were an estimated 247 million cases worldwide, with around 619,000 deaths.

Malaria does not spread person to person. Instead, it is caused by a parasite carried by a mosquito — most often female Anopheles mosquitoes, according to the WHO.

All five patients in the U.S. Have gotten treatment and are recovering, according to the CDC.

The health agency urged people to protect themselves against mosquitoes by wearing long-sleeved clothes and pants and using insect repellent. It also suggested getting rid of standing water, where mosquito eggs are laid and take other steps to control the insects.

Shingler said he did not expect to get malaria. He urged people to wear bug spray if they are working outdoors around mosquitoes.

"I didn't fully grasp how impactful this was until I was reading the news and I saw article after article after article saying, 'Hey, the first ever case of malaria locally in Texas in 20 years,' he said. "I was like, 'Wow, that's actually kind of crazy.'"

"I don't think anybody even thought that that was a thing that could happen," he added. "At the end of the day, I think it was just pure coincidence that I happened to get it."

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