Health Europa Quarterly highlights the work of the Bill & Melinda Gates Foundation to eliminate infectious and tropical diseases.
The Bill & Melinda Gates Foundation was born in 1997 when married philanthropists Bill and Melinda Gates were moved by a newspaper article to address the high numbers of children in low-income countries who were still being killed by diseases that had long been eliminated in the US. Officially launched in 2000, it is today the world’s largest private foundation, and is committed to improving the health, quality of life and opportunities of people all over the world.
Here, Health Europa Quarterly explores how the foundation is working to reduce the global burden of infectious and tropical diseases such as malaria, dengue fever and tuberculosis.
In 2016, Europe became the first WHO region in the world to be declared malaria free, after dropping from 90,712 indigenous cases in 1995 to none in 2015.
Dr Zsuzsanna Jakab, WHO regional director for Europe, hailed the achievement as a “major milestone in Europe’s public health history and in the efforts to eliminate malaria globally”, and praised the “strong political commitment from European leaders” that had made it possible.
But while Europe cemented its malaria-free status for a second year in 2017, globally the malaria response has hit a roadblock.
In its World malaria report 2017, the WHO said that more countries are on the path towards elimination, but warned that a funding boost is needed to reach global targets.
WHO director general Dr Tedros Adhanom Ghebreyesus explained: ‘Last December, we noted a troubling shift in the trajectory of this disease. The data showed that less than half of countries with ongoing transmission were on track to reach critical targets for reductions in the death and disease caused by malaria. Progress appeared to have stalled.
‘The World malaria report 2017 shows that this worrying trend continues. Although there are some bright spots in the data, the overall decline in the global malaria burden has unquestionably levelled off. And, in some countries and regions, we are beginning to see reversals in the gains achieved.’
Indeed, despite falling from 237 million in 2010 to 211 million in 2015, the global number of malaria cases rose by five million in 2016, and conservative estimates put the number of malaria-related deaths at 445,000 – just 1,000 fewer than in 2015.
The majority of this burden was concentrated in 14 countries in sub-Saharan Africa, which, alongside India, accounted for 80% of all deaths.
The report highlights another worrying trend: just $2.7bn (~€2.2bn) was invested in efforts to tackle malaria in 2016, less than half of the $6.5bn that will be required annually by 2020 if the targets of the WHO’s ‘Global Technical Strategy for Malaria 2016-2030’ are to be met:
- Reduce malaria mortality rates globally compared with 2015 by at least 90%;
- Reduce malaria case incidence globally compared with 2015 by at least 90%;
- Eliminate malaria from countries in which malaria was transmitted in 2015 in at least 35 countries; and
- Prevent re-establishment of malaria in all countries that are malaria-free.
The Bill & Melinda Gates Foundation is at the forefront of efforts to eliminate malaria
It is with these targets in mind that the Bill & Melinda Gates Foundation is working to end malaria, which it defines not simply as interrupting transmission but as ‘removing the parasites that cause human malaria from the human population’.
Its multiyear malaria strategy (‘Accelerate to Zero’) is founded on the principles that elimination can be expedited by:
- Developing new drug regimens and strategies that achieve complete parasitological cure of affected individuals;
- Targeting asymptomatic infections – which represent the majority of infections – through community-based interventions;
- Developing new tools to address drug and insecticide resistance; and
- Developing and implementing strategies at a local or regional level.
To this end, the foundation divides its work into three main priority areas.
Per its website, the Bill & Melinda Gates Foundation is ‘generating evidence that malaria can be eliminated even in diverse geopolitical and transmission zones, including Southern Africa and the Greater Mekong Sub-region’. (Indeed, the number of reported malaria cases in the six countries of the GMS declined by 74% between 2010 and 2016, although emerging drug resistance is complicating the eradication effort.)
The foundation is thus working to bolster malaria campaigns by ‘improving the delivery of existing vector-control tools, diagnostics, and drugs; investigating the potential of existing drugs to achieve complete cure at the individual and population levels, including the asymptomatic reservoir; and refining strategies for reaching special populations, such as pregnant women and children’ under the age of five.
Funding transformative interventions
As well as exploring new ways to use existing tools, the Bill & Melinda Gates Foundation is investing in a series of new interventions to facilitate faster elimination.
Among these are vaccines that block transmission and prevent infection, single-dose fixed combination drugs that are safe and well tolerated, new and better vector-control tools, high sensitivity diagnostics, and – using the success of polio and smallpox campaigns as a template – more effective surveillance methods.
Malaria on the agenda
Central to the success of all efforts to eliminate malaria is adequate political support. To this end, the Bill & Melinda Gates Foundation works to ensure that malaria maintains its place on the international agenda by lobbying for national and global policies and funding, in addition to assisting countries to in their own ‘efforts to lower the malaria burden and scale up successful interventions’.
In line with this, in January the foundation announced it had partnered with the Inter-American Development Bank (IDB) and the Carlos Slim Foundation to launch the Regional Malaria Elimination Initiative (RMEI), which will support the implementation of country elimination plans in Belize, Costa Rica, the Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua and Panama.
“This collaboration will build on each of the partners’ unique capabilities and expertise to cover financial and technical gaps in the region, demonstrating that we can eliminate malaria today using current tools,” explained Bill Gates.
“It will also help strengthen health systems in the region, positioning countries for success against other high-priority vector-borne diseases such as Zika, dengue and Chikungunya.”
The RMEI is funded to the tune of $83.6m and, according to the IDB, is expected to leverage more than $100m in domestic financing and $39m of existing donor resources across the seven countries by 2022 ‘to ensure malaria remains a top health and development priority despite dwindling numbers of cases’.
“The IDB believes that eliminating malaria can only be achieved through sustained financing for locally-tailored approaches,” said IDB president Luis Alberto Moreno.
“By combining IDB resources with local and international contributions to tackle a regional problem, this initiative also exemplifies the ‘blended finance’ model that will increasingly offer the best means of achieving the Sustainable Development Goals.”
Like malaria, dengue fever is a mosquito-borne disease that results in flu-like symptoms such as muscle pain, headache, and nausea and vomiting. Although not typically fatal, in severe cases, it can develop into dengue haemorrhagic fever, which according to the WHO is now a leading cause of hospitalisation and death in countries in Asia and Latin America.
The World Health Organization estimates that 40% of the global population is at risk of dengue, which has witnessed a dramatic 30-fold increase in incidence over the last 50 years and in 2016 saw close to 1.5 million cases in Brazil alone.
The Bill & Melinda Gates Foundation is championing the use of new weapons to wipe out dengue fever
Supported by the Bill & Melinda Gates Foundation, among others, the not-for-profit World Mosquito Program (WMP) is working to reduce the threat of dengue by pioneering a safe, natural and effective method of vector control.
Wolbachia is a naturally occurring bacteria that is present in many insect species but not typically the Aedes aegypti mosquito, the main vector responsible for transmitting dengue.
Research by the WMP, formerly Eliminate Dengue: Our Challenge, has, however, demonstrated that the introduction of Wolbachia to A. aegypti reduces the mosquito’s ability to transmit dengue, as well as the Zika and chikungunya viruses.
The idea is simple: the WMP releases Wolbachia-carrying A. aegypti into the wild mosquito population, they breed, and the bacteria are passed on to subsequent generations. The result is a reduced risk of dengue outbreaks.
The WMP notes that this method is unique in being self-sustaining (once the Wolbachia-carrying A. aegypti have been introduced into a particular community, the intervention does not need to be repeated), but also affordable and long term.
What’s more, the technique is safe to humans and animals and does not pose any danger to natural ecosystems, unlike other uses of Wolbachia which have attempted to suppress mosquito populations.
The WMP began in Northern Australia in 2011 and, having been endorsed by the World Health Organization, is now being trialled in ten countries, including India, Vietnam and Brazil.
Tuberculosis (TB) is the world’s deadliest infectious diseases and one of the top ten leading causes of mortality, being responsible for 1.7 million deaths in 2016 and more than ten million cases of ill health.
TB is preventable and curable: the WHO estimates that 53 million lives were saved between 2000 and 2016 thanks to diagnosis and treatment.
Nonetheless, millions of people with TB continue to miss out on appropriate care every year, and efforts to end the epidemic are being put at serious risk as a result of drug resistance, which represents an increasing threat to global public health (approximately 490,000 people developed multidrug-resistant tuberculosis in 2016, according to the WHO).
Shortfalls in funding represent another obstacle to progress. The WHO End TB Strategy aims at delivering a 35% decline in TB deaths and a 20% reduction in incidence compared to 2015, as well as ensuring that no TB-affected families face catastrophic costs as a result of the disease.
To achieve these targets, the Stop TB Partnership’s Global Plan estimates that $67bn-worth of investment will be required between 2016 and 2020 – $58bn to implement TB prevention, diagnostic and treatment interventions and $9bn for global R&D. In 2017, the funding gap was estimated at $2.3bn.
The Bill & Melinda Gates Foundation is dedicated to accelerating the global decline in tuberculosis incidence
Against this background, the Bill & Melinda Gates Foundation is committed to advancing understanding of the basic science behind tuberculosis, improving the delivery of care, and supporting the development of new tools for prevention, diagnosis, and treatment.
It divides its work along five priority areas.
Safer, more affordable treatment regimens
TB drug regimens are complex, lengthy, expensive, and frequently poorly tolerated thanks to side effects such as hearing loss and nausea.
The Bill & Melinda Gates Foundation is thus working to develop more effective treatment regimens via its TB Drug Accelerator and Critical Path to TB Drug Regimens initiatives.
The former unites academia with industry to develop new tools for drug discovery, while the latter takes on increasing drug resistance by bringing together pharma companies, public health experts, NGOs and regulatory authorities to accelerate the process by which new regimens are developed and tested.
Better tools for diagnosis
Of the estimated 10.4 million people newly affected by tuberculosis in 2015, more than 40% (4.4 million) went undiagnosed and/or unreported – an omission that has contributed in no small part to TB becoming the world’s leading infectious disease killer.
The Bill & Melinda Gates Foundation is working to tackle this by supporting the development of cheaper and better diagnostic tools, as well as communication systems to make treatment and care more accessible.
In particular, and per its website, it is ‘working on next-generation TB diagnostic tests based on samples that are easier to obtain than sputum, including blood, urine, and potentially even breath or sweat’.
The site adds: ‘While these techniques are in the early stages of development, we remain committed and optimistic that they will markedly improve TB detection, facilitate faster treatment, and reduce transmission.’
Delivering an effective vaccine
The BCG, the only TB vaccine in existence, has limited efficacy against pulmonary tuberculosis and is largely ineffective for adults.
The Bill & Melinda Gates Foundation is thus working to elucidate our understanding of the mechanisms of TB protection, with a view to identifying and progressing promising vaccine candidates through clinical trials.
To this end, in 2014 it launched the Collaboration for TB Vaccine Discovery, an international platform that facilitates the exchange of ideas and expertise between TB scientists.
Improving care and adherence
In order to expand access to high-quality diagnosis and treatment, the Bill & Melinda Gates Foundation is working alongside the government in India to integrate TB control into the private healthcare sector, which according to the Global Coalition Against TB treats an estimated 50% of all TB patients, and with authorities in China to promote a move to hospital-led care.
It has also partnered with the Global Fund, the WHO, and the global health initiative Unitaid to maximise the impact of resources and funding, and is championing the use of adherence technologies to ensure that patients who begin a course of treatment complete that course of treatment.
Advocating an end to TB
Lastly, the Bill & Melinda Gates Foundation works to mobilise support from governments, pharma and the biotechnology industry to ensure that adequate resources and political will are in place to drive progress in the fight against TB.
The Moscow Declaration to End TB
These priorities are closely aligned with the recent Moscow Declaration to End TB, which was adopted by 118 national delegations in November following the First WHO Global Ministerial Conference on Ending TB in the Sustainable Development Era: A Multisectoral Response.
The declaration represents a collective commitment to increase efforts to end TB in four ways:
- Advancing the TB response within the SDG Agenda: ministers committed to, among other things, moving towards universal health coverage, prioritising vulnerable populations, addressing drug resistance, and tackling HIV and other TB co-infections;
- Ensuring sufficient and sustainable funding: ministers committed to mobilising domestic financing, developing and implementing fully funded and ambitious national TB policies, and making efforts to limit the expenses of TB on affected individuals and their families;
- Pursuing science, research and innovation: ministers committed to boosting multidisciplinary research funding, improving the co-ordination of research efforts, and fortifying surveillance systems, data collection and reporting; and
- Developing a multisectoral accountability framework (MAF): ministers committed to supporting the development of an MAF to track progress towards the SDG targets.
In addition to informing future elimination efforts as a whole, the promises laid out in the declaration will feed into the first UN General Assembly High-Level Meeting on TB, which will take place later in 2018.
How far these steps will ultimately go to bringing about an end to this devastating disease remains to be seen, but as long as the Bill & Melinda Gates Foundation exists, it is clear that tuberculosis – and other infectious disease killers like it – will remain a key topic of discussion for the WHO, UN and authorities the world over for many years to come.
This article will appear in issue 4 of Health Europa Quarterly, which will be published in February.