But the world can't wait another 25 years for the perfect malaria vaccine, says Ballou. Instead stakeholders need to seize
whatever approaches work today.
What will it take to end malaria? It will certainly require relying on some old lessons, such as those learned when WHO backed
off from its malaria-prevention efforts in the '70s. But even more, it will need new thinking, new tactics, and, especially,
new money. Here are some ways it's being done.
Combination approach The individual tools for fighting malaria may be imperfect, but taken together they can be powerful. That was the case in
Zanzibar, which used money from the Global Fund and the Presidential Malaria Initiative to mount a full-on attack: insecticide-treated
bed nets, diagnostics, ACTs, and indoor insecticide spraying. As a result, malaria cases dropped dramatically, with five major
hospitals recording an 87 percent decrease. The reduction was so rapid that Zanzibar ended up with excess ACTs, which it donated
to East African countries with shortages.
"In essence, Zanzibar has turned into a proving ground," says MMV's Hentschel. "It has gone from a situation where malaria
was the biggest cause of childhood mortality to something that is fairly rare in a very short time, just by using everything
Package of prevention The epidemics of malaria and HIV overlap in Africa and, some argue, should be treated together. One major barrier, says the
CDC's Slutsker, is the lack of data to support how ACTs work in HIV-immnosuppressed people.
However, there's innovation to be had on the prevention side. Malaria and HIV act synergistically in pregnant women to contribute
to adverse birth outcomes, such as low birth weight, says Slutsker. Therefore, in the reproductive health setting, women should
receive a prevention package including counseling on prevention of mother-to-child transmission of HIV and an insecticide-treated
Cheaper drugs By working with growers, Novartis was able to drop the price of Coartem. But further innovations may come from the lab, not
the land—as RBx11160 almost proved. Still, researchers from the University of California, the California Institute of Quantitative
Biomedical Research, and Amyris Biotech are forging ahead by working on synthesizing artemisinin. "Once you have a synthetic
product," says Columbia's Waldman, "malaria will become a 'solvable problem' like HIV" because manufacturing it will no longer
depend on the costly and variable availability of sweet wormwood trees.
In addition, three Indian generic companies have recently submitted ACTs for WHO's prequalification program, according to
Bosman. If these drugs are approved, ACTs may become a competitive market with lower prices for all.
Public health Phase IV The issue of malaria resistance has demanded that organizations pay more attention to adherence. One result has been the
creation of a support infrastructure to conduct outcomes studies in real-world settings—which public health officials can
rely on to make policy and treatment decisions.
"It's really the public health sector equivalent of pharma's Phase IV program, but for ACTs—and about establishing appropriate
relationships so that it can serve a market it doesn't understand," says Thomas Kanyok, a scientist for WHO's special program
for research and training in tropical diseases. "There is more interest in looking at larger issues like pharmacovigilance—there
are no systems like that in Africa."
Basic research Malaria needs more research into the mechanism of the disease. A key recent breakthrough came from the Broad Institute, where
researchers mapped the genetic diversity of the malaria parasite. "One of the immediate applications is to spot evidence of
the emergence of resistance to drugs that are just now being deployed—a kind of early warning surveillance system," says Dyann
Wirth, director of Harvard's malaria initiative. "This can help researchers track mutations and update the vaccine, the way
it's done with the influenza vaccine."