Breakthroughs Blog: Malaria

A Kenyan women poses with her baby son Ethan, who was in the hospital for 2 weeks with malaria. Photo: PATH/Gabe BienczyckiGlobal efforts to tackle malaria have proved hugely successful over the last 16 years, with more than 6.8 million lives saved. Yet, these gains are at risk. As we are seeing across all microbial diseases, the development of drug resistance is a huge threat. There is an urgent need to discover new medicines with novel mechanisms of action able to treat resistant parasites to ensure malaria patients can continue to be cured and we can continue the drive to end malaria for good. The traditional approach to drug discovery is clothed in secrecy, as scientists compete to find the next billion-dollar blockbuster. For "diseases of poverty" such as malaria, however, the low commercial value of the end product means that the need for confidentiality and competition is reduced, if not counterproductive. Scientists across the world are now starting to open up drug discovery research for these diseases with exciting results. MMV’s approach for malaria Medicines for Malaria Venture (MMV) is a nonprofit organization working with partners around the world to bring forward the next generation of antimalarials to tackle challenges like drug resistance. Our approach to drug discovery is “open innovation.” Over the years, we have built up a community that shares data and assays among a set (or subsets) of partners for a given project or projects. These open innovation projects are not transparent to the outside world, rather they operate within contractual “bubbles,” with a semi-permeable membrane securing confidentiality. For example, from 2008 to 2014, MMV and partners conducted an extensive screening campaign to stir up new chemistry for drug discovery projects. More than six million compounds were screened against the parasite, generating tens of thousands of new chemical starting points. One series, known as the aminopyridines, were identified through a screen performed by scientists from Griffith University, Australia. The series was then selected and explored further by a team of scientists at the University of Cape Town, South Africa, working in collaboration with scientists at MMV. With parasitological support from the Swiss Tropical and Public Health Institute and drug metabolism expertise from Monash University, Australia, the South African team selected the most promising compounds from the series for optimization and re-testing. In 2014, it became the first new antimalarial medicine to enter phase 1 studies in Africa. Today, preparations are being made to begin a phase IIa trial on this promising compound as a single dose cure. The advantage of this open innovation approach is that it allows MMV to tap into a wide range of expertise and existing research facilities—as well as share early proprietary knowledge among a select group of partners—together with risk, cost, and effort.Opening up beyond malariaWith the success of the screening campaign and open innovation approach for malaria research, we were keen to apply the learnings and lessons to other neglected diseases. In 2010, following the screening campaign, GlaxoSmithKline, the Genomics Institute of the Novartis Research Foundation, and St Jude Children's Research Hospital in Memphis, Tennessee, released the details of 20,200 compounds active against malaria into the public domain. The research community responded largely with enthusiasm, yet many felt blocked without physical access to the compounds. MMV responded in December 2011 by launching the open access Malaria Box, making 400 diverse compounds divulged by the screening campaign available for free. Since its launch, more than 250 copies of the Malaria Box have been delivered to researchers in 30 countries to catalyze malaria and neglected diseases drug research. All that was asked in return was that the researchers continue the virtuous cycle of sharing and collaboration by releasing their data into the public domain. Researchers screening the Malaria Box found hits against 16 different protozoa, seven helminths, nine bacterial and mycobacterial species, as well as the dengue mosquito vector and human cancer, many of which are undergoing further research today. The big lesson here is that compounds active against one disease (malaria) can be repurposed for a range of other diseases. Based on this and the successful uptake of the Malaria Box, MMV launched the Pathogen Box in 2015, comprising 400 compounds with activity against malaria or one of a range of other neglected diseases. This box, alongside several Challenge Grants awarded to promising projects, are not only catalyzing neglected diseases drug discovery, but also helping to support researchers in disease-endemic countries and bringing forth future generations of scientists.In this vein, our next initiative is the Pandemic Box, which will include antiviral and antibiotic compounds—again, at no cost to researchers. The goal is to provide chemical starting points for drug discovery for diseases like Zika and Ebola, as well as repurpose compounds for malaria and neglected diseases. This will be a joint project between MMV and Drugs for Neglected Diseases initiative. Can we open up further?Exploring the possibility of working completely in the open, in another project with Dr. Mat Todd of the University of Sydney, Australia, we have broken the membrane and created an Open Source Malaria drug discovery project. Essentially, everything related to the project is entirely in the public domain so that anyone, anywhere can follow and contribute. The idea is that it will work by “natural selection”—anyone can work on the shared data and, over time, the project will evolve. In this case, the best ideas will be prioritized and a new candidate drug for malaria will hopefully emerge.So far, the project has taught us that there is a enormous willingness to contribute and share expertise, but money and resources are still rate limiting. If people don’t synthesize compounds in a reasonable timeframe, research comes to a halt. MMV believes in open source approaches, but realizes they need a sustainable supply of resources and more importantly, focus. With limited resources, it is important to prioritize the most promising ideas.Working in partnership to end malaria for goodThese different knowledge-sharing projects clearly demonstrate that through collaboration we can achieve so much more than if we go at it alone. Since 2010, MMV’s collaborations have delivered 17 candidate molecules for malaria. This has created a strong pipeline, but many more candidates are needed if we are to succeed in defeating malaria. We continue to enlarge our partnership network and explore new ways to open up drug discovery research for the global good.

Science expands our understanding, makes the impossible possible, and helps us build the future we want for all people. Science drives the work of our Global Health Technologies Coalition, so we wanted to take a step back to reflect on five ways science is transforming global health:1. Science is generating treatments, cures, and vaccines to tackle the world’s most devastating diseases.  From a vaccine that has put us at the brink of eradicating polio to antiretroviral treatments that have dramatically extended the lives of people living with HIV and AIDS, science has generated new health technologies that have driven tremendous progress in global health. Thanks to investments in science and research, 82 new vaccines, drugs, diagnostics, and other lifesaving global health tools have been developed and introduced since 2000. These tools include a new meningitis A vaccine—which has already saved 378,000 lives and prevented 673,000 new infections since 2010—and new child-friendly malaria drugs that have helped cut childhood malaria deaths by 65 percent since 2000. Science has also fueled a robust pipeline of over 670 global health technologies now in development poised to further build upon these gains.2. Science is helping us understand the unique needs of users and communities so we can design the right tools for impact. A scientist assembles a point-of-care diagnostic test. Photo: PATH/Dan ChangDriving progress in global health is not just about developing tools that work; it’s about developing tools that work for the communities and contexts in which they are used. A diagnostic test won’t help us identify and control an emerging epidemic unless it can be administered on the spot in remote communities and deliver results quickly. Likewise, a woman is not likely to adopt a new contraceptive or HIV and AIDS prevention method unless it’s easy-to-use, comfortable, affordable, and fits in with her lifestyle and culture. Through surveys, data analysis, diagnostics, and user testing, science is enabling us to study end users and the environments and social systems in which they operate. This helps us better understand the complexity of their unique needs and design and refine technologies to deliver the most effective solutions for impact.3. Science is helping us predict, detect, and track emerging health risks so we can be better prepared to confront tomorrow's challenges. From using weather patterns to forecast the risk of insect-borne disease outbreaks, to employing genomics and evolutionary theory to predict how bacteria will become resistant to antibiotics, to advancing new hybrid systems that combine crowdsourced data with traditional disease surveillance, science is helping us better predict, detect, and track infectious disease outbreaks and other emerging health challenges. Early detection can make the difference between an outbreak becoming an epidemic and is critical to mounting an effective response.4. Science is helping us understand what works and what doesn't so we can better target interventions and design health programs for maximum impact.  How often does an insecticide-treated bed net need to be replaced, and how many tears can it sustain before its stops working? In an era of limited resources, can we predict which technologies and interventions are likely to save the most lives in a country if brought to scale? How do we get people to change their handwashing habits to reduce diarrheal disease and childhood deaths? These are the questions big and small that scientists, data analysts, and other health researchers are working to answer in labs, offices, and program sites across the United States and world. The answers they get are helping us better target health solutions and refine health programming to more save lives and more dollars.5. Science is putting information and data at our fingertips to help us fight global diseases and health challenges in new and unusual ways. The revolution in mobile technology, digital health, and big data is transforming our approach to fighting global diseases and health challenges. Health care workers are using mobile devices to track immunization coverage door-to-door and monitor vaccine supplies to prevent stockouts, doctors are using SMS to remind patients to take their tuberculosis drugs and treatment adherence, and health ministries are deploying new data visualization toolsto turn a mountain of data into accessible and actionable information to guide decision on to best deploy and target resources.Science creates a foundation upon which improvements in global health are built. It unlocks discoveries and fuels innovation, informs policies and programs, breaks down barriers, and ultimately advances better, healthier lives for all people. At this moment in time, it is more vital than ever that we build a convincing case of the benefits that flow from science and the importance of strong investment in science and research.In global health, science matters because #scienceserves and science saves.

In this regular feature on Breakthroughs, we highlight some of the most interesting reads in global health research from the past week. Scientists have identified a gene that stops tuberculosis (TB) from mutating and becoming resistant to antibiotics. Researchers at Centro Nacional de Biotecnología in Madrid and the University of Sussex in Brighton individually deactivated each of the 11,000 genes that make up the TB bacterium, and tested the modified strains against an antibiotic commonly used to treat the disease. The study revealed that the NucS gene, which produces an enzyme that repairs DNA, significantly reduces the frequency of genetic mutations, and consequently, the development of antibiotic resistance. As drug-resistant strains of TB have been reported in more than 100 countries, this discovery could pave the way for improved diagnosis and treatment, making it easier for clinicians and researchers to predict which cases of TB will develop resistance. The US Agency for International Development (USAID) is the largest donor of food aid worldwide, spending US$1.5 billion on wheat, sorghum, rice, and other edible commodities annually. As the food travels around the world, an estimated 1 percent is lost to spoilage, which amounts to 10,000 tons of food worth $15 million. Now, researchers at the Massachusetts Institute of Technology are exploring new ways to package the food to avert spoilage and are testing eight different bags of varying sizes and materials to determine their ability to protect against humidity, water damage, and pests. One model has a completely airtight liner that resists moisture, while another uses a biopesticide that stops insects from reproducing, rather than killing them. The research team is also investigating the use of an airtight liner for the shipping containers, rather than the bags themselves. The final results and recommendations will be available this summer. Gene drives, a promising technique for eliminating mosquitoes and eradicating mosquito-borne diseases, may be stymied by evolution. The novel method involves genetically modifying mosquitoes by introducing an unusually dominant genetic mutation that is passed on to the insects’ offspring, overtaking an entire population of mosquitoes within a few generations. To combat malaria, Zika, and other mosquito-borne diseases, scientists have engineered mosquitoes whose offspring are infertile, and initial trials suggest that gene drives could be a breakthrough in vector control. However, additional research indicates that as these manmade genetic mutations spread through a population, so too do natural mutations that counteract the effect. Furthermore, there is an immense amount of genetic variation among mosquitoes, which limits the potential targets for gene drives. To overcome this, some researchers are introducing multiple genetic mutations at once, however, it remains to be seen whether the manmade or natural mutations will be more powerful.

Scientists at the University of Oklahoma are looking for the next breakthrough drug in an unusual place: roadkill. Every animal hosts a unique microbiome—a community of microorganisms, including bacteria, fungi, and molecules with antibacterial and antifungal properties. The research team is collecting swabs from dead animals found along a state highway and has already discovered two compounds (taken from an opossum’s ear) that could prevent the spread of yeast infections. Hypothermia is a significant driver of morbidity and mortality among babies born prematurely, even though the condition is easy to detect and treat. Detection relies on temperature monitoring, and current standard of treatment is Kangaroo Mother Care (skin-to-skin contact). Now, an electronic alert bracelet is being used to prevent hypothermia among preemies in India. If the infant is healthy, the bracelet flashes a blue light every ten seconds; if the infant’s temperature drops, the light turns to red and an alarm goes off. The single-use device is safe and can be used for a month straight—even at home. Though a daily dose of pre-exposure prophylaxis (PrEP) can prevent HIV infection, stigma, cost, and frequent stockouts can impede adherence to the regimen. While only four doses per week is sufficient to protect men from infection, if women miss a single daily dose, they risk infection. To mitigate these barriers, researchers at Intarcia Therapeutics Inc. are developing an implant that would release PrEP over time, meaning just one visit to the doctor’s office would protect patients for an entire year. The device has already undergone advanced testing and is currently under review by the US Food and Drug Administration for the delivery of diabetes drugs. Researchers at the Center for Infectious Disease Research (CIDR) in Seattle are using mosquitoes, rather than syringes, to deliver an experimental malaria vaccine. The vaccine uses live, but weakened malaria parasites, which can only grow inside living mosquitoes. In an initial trial, ten volunteers were vaccinated, none of whom developed malaria and all of whom produced antibodies that could confer immunity against malaria. The antibodies were extracted from volunteers and successfully used to protect mice against malaria, however, additional trials are needed to determine their efficacy in humans. CIDR is partnering with the Maryland-based biotech company Sanaria to develop a more standard and sustainable vaccine delivery system, producing the weakened parasites and extracting them from the mosquitoes, and attempting to grow the parasites outside of the mosquitoes.