Next-generation vector intervention for malaria control

The increased frequency and force of major cyclones hitting particularly East Africa, droughts across Northern Africa, air pollution related illness and deaths (major contributors to cardiovascular disease), food shortages and biodiversity crises are all symptoms of how human activities have perturbed planetary health. Increasingly, across sectors, it is clear that transformation is needed to reduce our collective adverse impacts. For malaria mosquito control, the use of preventive interventions are recommended by the World Health Organization (WHO). The WHO pre-qualifies interventions and strategies based on the assessed quality of data evidencing individual-, household- and community-level benefit across socio-ecological settings. This critical role of the WHO collates the best available data on epidemiological effectiveness. Currently, only insecticide treated nets (ITNs) and indoor residual spraying of insecticide (IRS) are considered core interventions within the WHO guidelines. This matters; as countries develop their national strategies, funding core interventions already stretches tight budgets leaving other options less affordable. Strategising the use of different combinations of interventions is understandably a complicated juxtaposition where National Programs, donors and implementers are trying to maximise their impact and make decisions on robust data, but ITNs and perhaps IRS, are reaching a limit on what they can achieve. The set of interventions that we probably need to reach malaria eradication, particularly on the African continent where malaria burden is highest and ecological circumstances make the challenge greatest, will require multiple approaches. Manipulating the ecological base of a location to reduce mosquito-supportive features may be a key component. So far, this FLF project has focused on characterising epidemiological impacts from a range of WHO recommended interventions. We have developed a webtool (MINT) to explore complementary intervention use across settings to support the decision-making process, and now intend to extend this to additional strategies. Our decisions framework is established to consider financial costs and epidemiological impact. However, the urgency to deliver protective strategies has an inadvertent ecological cost. Current statistics indicate that health care contributes around 5% to global greenhouse gas emissions1, and ITNs are expected to produce around 57,500 tons of plastic waste annually by 20302. While emissions-costly activities that address immediate public health needs should be arguably protected, we – as global health stakeholders - can pioneer the necessary transition. This project now aims to redirect malaria vector control toward a sustainable framework that holds environmental health at its core. To do this, we will develop a metric, akin to the Incremental Cost Effectiveness Ratio, ICER, that includes an environmental assessment: an "Incremental Cost Effectiveness and Environmental Impact Ratio”, ICEEIR. Life Cycle Assessments and transmission model simulations will be combined so that vector control commodities and delivery strategies can be compared using this ICEEIR. The WHO guidelines provide the evidence and status of preventative interventions based on epidemiological and entomological performance. This project aims to add evidence of device specific environmental considerations. This will provide countries, donors and the WHO, who are taking decisions with scaled outcomes, the information that can enable decisions that minimise adverse environmental consequences and climate emissions, while delivering efficacious and affordable health care. Manufacturers can be incentivised to deliver ecologically-considered devices through this transparency helping malaria control to play a leading role in the necessary global transition toward ecological health. Or et al. 2024. https://doi.org/10.1016/j.healthpol.2024.105053. Unitaid. 2023. From Milligrams to Megatons?