The innocuous buzz of a mosquito might be all the warning you get; by the time you notice the itchy bite on the back of your arm, it’s too late. The plasmodium parasite has already been transmitted through the insect’s saliva and now entered your bloodstream. It’s only a matter of days before you are gripped by the full force of malarial fever and aching muscle…
Malaria is endemic to the Asia-Pacific, with parts of Vietnam and the greater Mekong region (Cambodia, Laos, Thailand and Myanmar) particularly susceptible to deadly strains of the disease.
The Vietnamese government first recognised malaria as a health crisis in 1991, when there was an unprecedented spike in disease-related death. Treatment was made a national priority and health spend was exponentially increased – from half a million dollars, to almost six million – in an effort to curb the high mortality rates.
Since then, Vietnam has made significant progress towards eliminating the mosquito-borne disease and has seen an 85% reduction in malaria deaths within the last decade.
The country has made a commitment to be declared malaria-free by 2030, and is working as part of the Asia-Pacific Malaria Elimination Network (APMEN) to achieve this goal.
APMEN Co-Secretariat, Professor Maxine Whittaker, has been involved in the anti-malarial movement since it’s beginning and is confident these targets can be reached.
“When we set our vision for the Asia-Pacific, it was not something we decided sitting in D.C. or Canberra or Geneva. We were looking into each country’s national malaria strategy and their government’s own commitment to malaria control and, based on that, we were able to see that widespread elimination by 2030 is achievable.”
Vietnam has asserted itself as one of the front-runners in the race to eliminate malaria within its borders.
“Vietnam is definitely on track and many people think they may even be able to eliminate malaria earlier than they’ve said. Obviously though, if they set the goal too early and they don’t reach it, that can be quite disheartening. So they’re probably just being a little cautious at the moment, but we all know they can do it.”
Vietnam’s Prime Minister, Nguyen Tan Dung, jointly established the Asia-Pacific Leaders Malaria Alliance (APLMA) in 2013 with Australian counterpart, Tony Abbott, and remains actively invested in eliminating the disease.
This level of political engagement underlies Vietnam’s strong stance against the spread of malaria and, according to Professor Whittaker, is something APMEN’s sixteen other regional partners wish to emulate.
“They set the bar pretty high. Many other countries want to learn how Vietnam got such high-level leadership to be so supportive of the cause, and how they have been able to advocate so effectively.”
The coastal city of Hoi An, in Vietnam’s Quang Nam province, has also opted to host APMEN’s annual meeting for 2015, with relevant leaders meeting to discuss a “road map” towards malaria elimination. Strategies needed to fill knowledge gaps and capitalise on gains made in the Asia-Pacific will also be on the agenda.
Professor Whittaker believes it is an opportunity for Vietnam to showcase the good work being done there, and continue building momentum in the region as their elimination target of 2030 approaches.
“Vietnam put up its hand and offered to host this year’s meeting so they could remind their government and healthcare sector of how important it is to continue malaria elimination efforts. They want to reinforce the message, ‘you can’t get this far and then not finish the job.’”
While fewer cases of malaria can be taken as a positive sign that intervention programs in Vietnam are working, it seems that these short-term successes are actually making it more difficult to implement ongoing elimination initiatives in the country.
One of APMEN’s priorities is trying to maintain the funding stream for anti-malarial health services once reported cases of malaria start to decline, before foreign investment perceives greater need elsewhere and pulls out.
“Donors think because malaria in the Asia-Pacific has been reduced by 48%, that it doesn’t require anymore financial assistance. Then the government starts saying, ‘malaria is not a problem, look at dengue and maternal mortality instead.’ But what people have to understand is that you need some money to get to the end, and almost there is not good enough.”
Professor James McCarthy from the Clinical Tropical Medicine Lab at Queensland’s Institute for Medical Research has been tracking malaria’s epidemiology and echoes these sentiments, after noticing a shift in recent times.
“Vietnam is a rapidly developing country with rising standards of living, which means malaria has become marginalised to rural areas in the country, bringing its own set of problems – as malaria becomes more remote, it becomes harder to treat because populations are harder to reach.”
Communities working in plantations along the Cambodian border are now at the greatest risk of infection. The poor health coverage and lack of education surrounding malarial symptoms in these areas is driving a greater incidence of the disease.
To combat these localised outbreaks, the Vietnamese government is channeling more resources than ever into its border regions. The core tenets of their revised malarial strategy are knowledge and capacity building.
“If locals get a fever then they should know how to access appropriate healthcare services, get a diagnosis, and then target their treatment. Access to good quality medicine that works, and works quickly, is really the backbone to eliminating malaria.”
At the moment artemisinin is the preferred anti-malarial treatment, but it is by no means a surefire solution. The fast-acting drug is so effective within the first twenty-four hours that many people choose not to complete their full course, inadvertently contributing to bio-medical resistance.
“Particularly in Cambodia and other areas in the greater Mekong region, we’re seeing parasites starting to develop that are resistant to the most important combination treatment we have on offer. This threatens the population with new strains of malaria we can’t even treat yet.”
Scientists are working towards concentrating artemisinin-based therapies into less than their current three-day dose, hoping it will encourage more people to complete the full course. But there are other unique challenges that Vietnam faces in the fight against resistant mosquitos, including the prevalence of counterfeit medicines.
“Unscrupulous individuals are manufacturing fake medicines and marketing them as the real thing. Often they will contain small traces of artemisinin, allowing parasites to develop immunity to an effective drug as they are exposed to an ineffective drug.”
While the damage cannot be undone, spreading awareness that anti-malarial medication is available for free could help curtail this practice. In the meantime, Professor McCarthy and his research team are focused on broadening the range of treatment options.
“We’ve got a number of malaria drugs that are in advanced stages of development and showing promising results in our testing. It might just be a few more years before they’re fit to be distributed to areas where there’s the greatest need, so there’s a real imperative for us to speed up development of these drugs.”
Breaking the cycle of transmission at a community level has centred on trying different ways to eliminate the anopheles mosquito from the ground up. Indoor residual spraying (IRS) and long-life insecticidal nets (LLINs) have been two of the most popular methods, adopted as part of government-sponsored health programs.
But just as some mosquitos have developed bio-medical resistance to anti-malarial medications, others are adapting to behavioural changes in the human host, demanding new vector control strategies.
Doctor Nigel Beebe from the Commonwealth Scientific and Industrial Research Organisation’s (CSIRO) Biosecurity Flagship has been monitoring genetic changes to anopheles mosquitos in the Pacific and acknowledges they are a resilient species that is adapting to survive.
“It’s all about understanding the biology and behaviour of the vector, in this case, the mosquito, coupled with the changing capabilities of the malaria parasite. It means we’re in a constant battle with evolutionary forces and we’re up against evolutionarily nimble creatures.”
In the border regions of Vietnam, where people spend a lot of their time outdoors, there is an evolutionary selection that favours mosquitos biting in the early evening. This means the parasite can be transmitted before people go inside their homes to sleep, rendering the protective bed nets largely ineffective.
Spraying hammocks with insecticides and lowering the cost of personal repellents are among the latest initiatives being trialed in Vietnam, but Dr. Beebe is mindful that it may take some time before they can identify what works best.
“The complexity of malaria and how it occurs in the landscape means you really have to tailor-make the vector control strategies in each region. The one-size-fits-all mentality is just not practical.”
Dr. Beebe is part of the solution, receiving a grant from the National Health and Medical Research Council at the end of 2014 to pursue innovation in the field of sterile insect technology.
“I’m trying to develop a way to release sterile male mosquitos into the environment, who will then hunt down females to mate with and – because female mosquitos only mate once – you can take that female out and, over a period of time, actually crash the entire population. It’s pretty exciting stuff.”
Vietnam is on the cusp of malaria-free accreditation and would be the first to achieve this status within the Asia-Pacific region (globally, joining the ranks of the United Arab Emirates, Morocco, Turkmenistan and Armenia who have all been certified malaria-free by the World Health Organisation).
Clearly, a lot is at stake in terms of the health outcomes for Vietnam’s population and moving forward will rely on active participation from all APMEN’s regional partners to achieve this common goal.
There is a need to join forces regionally and systematically tackle the disease throughout the Asia-Pacific, as cross-contamination from neighbouring countries threatens to undermine progress. This means equally targeted interventions must occur on both sides of the border between Vietnam and Cambodia to ensure the disease is eliminated once and for all.
In the same way, a sustainable funding model must continue to support rapid diagnostic tools and flexible treatment options for the Vietnamese. Getting this close to elimination puts the country in a precarious position – they either eliminate it entirely or are at greater risk of malaria resurgence, and without natural partial immunity could be exposed to more severe, even fatal, strains of the disease.
Professor Whittaker stresses the need for ongoing vigilance.
“If all the funding freezes up, then we haven’t got the capacity to identify cases coming into Vietnam and we won’t be able to stop it from spreading and taking on epidemic proportions. It would cause more deaths if we stopped now, so it would be almost unethical to not see this through, and do so at whatever cost.”
This comes at a time when the Australian government has cut its development budget and foreign aid contributions, making it increasingly difficult for organisations like APMEN to find the money to sustain their vital intervention programs.
It raises the question from a health security perspective, can we afford to abandon malaria elimination efforts at this critical time? Particularly given the potential health repercussions on a national and international scale. But there are also moral implications to consider, as we ask ourselves whether Australia can really put a price on good global citizenship?