A new strain of multidrug-resistant malaria has spread from Cambodia to Southern Vietnam and is now affecting the entire Greater Mekong Region of Cambodia, China, Laos, Myanmar and Vietnam. Malaria is a preventable and treatable disease; however, it can be deadly if not diagnosed and treated promptly. Malaria is transmitted through mosquito bites and is characterized by high fevers and flu-like symptoms.

Cambodia’s mutant strain of plasmodium falciparum, the most dangerous form of malaria, has recently developed new immunities to Vietnam’s most used antimalarial drugs – artemisinin and piperaquine. The arrival of this mutant strain in Vietnam was first reported on October 2017 by The Lancet for Infectious Diseases in a letter from scientists from Vietnam and Thailand. Mallika Imwong and her research partners warn that the new drug-resistant strain represents “one of the greatest threats to the control and elimination of malaria” [1]. The new strain is quickly outcompeting other forms of malaria and threatens to derail decades of work in reducing Vietnam’s malaria transmission and death-toll rates.

The Prevalence of Malaria in Vietnam

Malaria is most prevalent in tropical and subtropical climates. It has been eradicated in the developed world, but remains a problem in many countries in the developing world. In 2016 there were 216 million malaria cases reported worldwide resulting in 445,000 total deaths, mostly occurring in Sub-Saharan Africa [2]. In Vietnam, the World Health Organization (WHO) recorded 4,161 confirmed cases of malaria with 2 reported deaths, although the WHO’s estimates that up to 10 deaths may be attributed to the disease [3].

The Center for Disease Control reports that malaria is primarily present in rural areas in Vietnam, with most major cities, including Hanoi, Ho Chi Minh City, Da Nang, and Nha Trang, experiencing no malarial infections [4]. According to the Asia Pacific Malaria Elimination Network, ethnic minorities, forest workers, and migrants in Vietnam are affected at a disproportionate rate due to their lack of access to health resources and their proximity to areas with high-infection rates [5].

Programs to Combat Malaria

In 1992, Vietnam began to distribute insecticide-treated bed nets (ITNs) and long lasting insecticidal nets (LLINs) free of charge contributing to sharp decreases in malarial infection rates. Since then, Vietnam has seen a significant decrease in the number of malarial transmission from over a million cases documented in 1992. Since 2003, Vietnam has been distributing artemisinin-based combination therapies (ACTs) free of charge to their population. This has significantly reduced complications and deaths from the disease.

In the past five years, Maldives and Sri Lanka were both declared malaria-free by the WHO. Scientific American points to Sri Lanka’s successful programs to eradicate malaria as a model for other afflicted nations to follow [6]. Sri Lanka developed a multidimensional approach to treating malaria, including transmission prevention, parasite surveillance, patient monitoring, and prompt treatment of the disease. Vietnam has applied a similar cross-sectional approach with great success, including extensive community-focused health education, free access to preventative ITNs and LLINs, rapid diagnostic testing, and appropriate and free-access antimalarial treatments.  

Vietnam also collaborates with other members of the Greater Mekong Subregion to share best practices and implementation strategies to fight malaria. Together, they are actively working to eradicate malaria in the region by 2030. Vietnam’s efforts are supported by the WHO, the Asia Pacific Malaria Elimination Effort, and Vietnam’s National Institute of Malaria, Parasitology, and Entomology (NIMPE). According to a study by development economists John L. Gallup and Jeffrey D. Sachs, total eradication of malaria would have major positive effects on Vietnam’s economic growth, poverty reduction, and human development [7].

Decreases in Funding

Funding to treat and reduce malaria in Vietnam averaged a little over $10 million USD over the past 10 years, mostly from the Global Fund, government expenditures, and the WHO. The U.S. provides the largest source of international funding through USAID and the President’s Malaria Initiative (PMI) totaling $1 billion USD in global contributions in 2016.

Funding cuts represent a major challenge for the country’s health professionals. 2015 saw a sharp decline in Vietnam’s public expenditures as well as a large decrease in international funding from a high of more than $17 million in 2013 [3]. In May 2017, the US congress proposed to cut funding to the PMI by 44%. This would result in an increase of almost 300,000 deaths worldwide over the next four years based on a model developed by Imperial College London professor Peter Winskill [8]. This loss of funding would be catastrophic for the gains Vietnam has made in the treatment and prevention of malaria.

Potential to Continue to Spread

The rise of a malaria superbug seriously threatens Vietnam’s goals to eliminate Malaria by 2030 and could put thousands of lives at risk for contracting and dying from this preventable disease. There are a few new antimalarial drugs currently in late testing stages, but they are not expected to reach the market until after 2020 and researchers warn against creating a sense of “false confidence” against fighting this new malaria strain [9].

In December 2017, Doctors at Ho Chi Minh City’s Tropical Disease Hospital reported two deaths attributed to malaria in only two weeks [10]. This number is only likely to grow if more aggressive measures are not implemented by Vietnamese health authorities to respond to this new malaria strain. In a comment from Dr. Nguyen Hoan Phu from the Tropical Disease Hospital he urged Vietnam’s Health Ministry to increase its malaria education outreach programs and funding and distribution of malaria medication to provinces without current access to these services [10].

Vietnam must focus on enhancing their malaria monitoring and diagnosis, establishing greater cross-border collaboration with other Greater Mekong Region countries, and informing local hospitals to switch to new combination therapies to aid in fighting this new multidrug-resistant strain. It is also critical that Vietnam returns government funding levels to fight Malaria to 2005-2013 levels to respond to the potential for decreasing international funding.

If Vietnam fails to implement measures to effectively contain this new multidrug-resistant malaria strain, it threatens to spread to other vulnerable regions, including sub-Saharan Africa, where it would lead to a devastating loss of life and could escalate to a global emergency.

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Article written by MANUEL GUERRERO

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References:

[1] Imwong, M., Hien, T. T., Thuy-Nhien, N. T., Dondorp, A. M., & White, N. J. (2017, October). Spread of a single multidrug resistant malaria parasite lineage (PfPailin) to Vietnam. The Lancelet Infectious Diseases, 17(10), 1022-1023.

[2] World Health Organization. (2017, November 29). Key Points: World Malaria Report 2017. Retrieved from World Health Organization: http://www.who.int/malaria/media/world-malaria-report-2017/en/

[3] World Health Organization. (2017). Viet Nam Malaria Country Profile. Retrieved from World Health Organization: http://www.who.int/malaria/publications/country-profiles/profile_vnm_en.pdf

[4] Center for Disease Control. (2017, September 12). Vietnam: Areas of Malaria Transmission. Retrieved from Center for Disease Control

[5] Asia Pacific Malaria Elimination Network. (2016, September). Eliminating Malaria in Vietnam: Country Briefing. Retrieved from APMEN: http://apmen.org/apmen/Resources/Country%20Briefings/Vietnam2016_Final.pdf

[6] Midega, J. (2017, December 8). “Supermalaria” Is on the Way. Retrieved from Scientific American: https://blogs.scientificamerican.com/observations/supermalaria-is-on-the-way/

[7] Gallup, J. L., & Sachs, J. D. (2001, January). The Intolerable Burden of Malaria: A New Look at the Numbers. American Journal of Tropical Medicine and Hygiene. Retrieved from American Journal of Tropical Medicine and Hygiene

[8] Winskill, P., Slater, H. C., Griffin, J. T., Ghani, A. C., & Walker, P. G. (2017, November 21). The US President’s Malaria Initiative, Plasmodium falciparum transmission and mortality: A modelling study. PLOS Medicine, 14(11).

[9] Ives, M., & Jr., D. G. (2017, November 21). As Malaria Resists Treatment, Experts Warn of Global Crisis. Retrieved from New York Times: https://www.nytimes.com/2017/11/21/world/asia/malaria-drug-resistant-vietnam.html

[10] VietNamNet (2017, December 19). Medical workers fret relapse of malaria, drug-resistance. Retrieved from VietNamNet: http://english.vietnamnet.vn/fms/society/192260/medical-workers-fret-relapse-of-malaria–drug-resistance.html