Malaria has played a long and enduring role in human history. The disease is believed to have first emerged hundreds of thousands or millions of years ago. While our understanding of this parasitic disease has improved dramatically as contemporary science advances, researchers are still faced with the dilemma of developing relevant drugs and therapies against it.
Many antimalarial drugs have been developed, but all have lost their effectiveness due to the parasites’ ability to evolve and develop drug resistance. In the first decade of the 2000s, we saw that the most commonly used antimalarial drugs, the artemisinins, also started to lose their effectiveness. The resulting lack of treatment options has left patients and those at risk of contracting the disease — particularly those in low- and middle-income countries (LMICs) — in a vulnerable state.
When artemisinin first emerged as a treatment option in the 1990s, it was welcomed by some countries’ national malaria programs. Maciej Boni, an associate professor of biology at Penn State University, says of the importance of the drug: “A small series of clinical trials were conducted in South Vietnam in the 1990s. Although few were familiar with the drug before that, the studies proved its potency. Finally, artemisinin combination therapies were recommended by the World Health Organization in 2005
Today, artemisinin is the main treatment for malaria, but artemisinin resistance is now common in Southeast Asia and emerging in East Africa. To slow down this phenomenon and protect as many patient lives as possible (and for as long as possible), good drug surveillance will make all the difference. “Usually resistance arises very slowly and constant supervision is required. This means we need dedicated networks of scientists working on sample collection and genotyping,” says Boni. “By creating fast and responsive surveillance networks, we can help improve treatment in endemic countries and facilitate communication between public health agencies and patients.”
But proper surveillance depends on understanding the evolution of resistance in artemisinin and the partner drugs used alongside it in many parts of the world. Boni, along with colleagues from Penn State University, the University of Oxford and Imperial College London, has found that resistance to partner drugs also drives early resistance to artemisinin. He says: “We looked at the conditions that influence the evolution of resistance. The reason it was so hard to distinguish before was that the early stages of resistance come on slowly. Therefore, it is a challenge for public health systems to detect.”
In particular, the team’s research focused on artemisinin partner drugs piperaquine, amodiaquine and lumefantrine. To varying degrees, malaria has already developed some resistance to these drugs, but Boni and colleagues found that, when resistance levels of partner drugs are high, resistance to artemisinin evolves even faster than expected.
The discovery is just more evidence, he explains, that further surveillance is needed to control antimalarial resistance. Doing so will allow public health authorities and other healthcare stakeholders to better respond to resistance if and when it emerges. “If we take Rwanda as an example, we are already seeing signs of artemisinin resistance. With proper oversight, we should have a better idea of when to start enrolling patients in trials of alternative artemisinin-based combination therapies and see if the new treatment approach allows them to clear the parasite.”
Boni and his Penn State colleagues are now working with the World Health Organization and national malaria control programs to assess the current situation in Rwanda, Burkina Faso and other countries and make projections of what the next five to 10 years might look like.
“It’s hard to say what things will look like in five years,” he says. “Just as weather reporters can give a forecast for the next few days, but can’t say for sure what the weather will be like in the next month, we don’t know exactly what the future of malaria resistance will look like. That’s why it’s so important to think early about managing drug resistance.”
But effective management requires good financing. The better access researchers and national programs have to funding, the easier it will be to set up and strengthen management systems. Boni says: “In the next 10 to 15 years we need to channel more money into this area. We’ve come a long way when it comes to malaria; 15 years ago it was considered a neglected disease. While funding has exploded over the past two decades, which was the right thing to do, we need more of it to see a greater impact on patients’ lives. Imagine how far we can go with the right tools and resources.”
Making great scientific journals is not just about delivering high quality knowledge and content; it’s also about wrapping these in the right words to make sure someone gets really inspired by a topic. It is my passion to ensure that our authors’ expertise is presented as a seamless and enjoyable reading experience whether in print, digital or on social media. I have spent fourteen years writing and editing features for scientific and production publications, making this content attractive and accessible without sacrificing scientific integrity. There’s nothing better than a magazine with great content that’s a joy to read.