Professor Halidou Tinto (Institute of Research in Health Sciences (IRSS) - Clinical Research Unit of Nanoro (CRUN), Burkina Faso) discusses his research activities on malaria clinical trials and reflects on all the challenges faced during 2020 and how he foresees 2021.
Q: Could you tell us a little bit about yourself and the focus of your current research?
Halidou Tinto (HT): I am Halidou Tinto. I come from Burkina Faso where I am working at the Regional Direction of the Institute for Health Sciences Research (IRSS) based in Nanoro. I am a Pharmacist and medical scientist by background. My research activities, initially oriented towards the epidemiology of malaria drug resistance, are currently focused on malaria clinical trials (drugs & vaccines).
Q: The World Malaria Report 2020 was published a couple of weeks ago, highlighting 20 years of global progress and challenges. When thinking about challenges, which are the main ones that come to your mind?
HT: Indeed, the 2020 world malaria report has shown the magnitude of the great progress made during the last 20 years toward a world free of malaria. However, effective malaria control and elimination have been on the global health agenda since 1960, but we are still aiming to control malaria in most parts of the world. This means that effective tools necessary for malaria elimination are yet to be developed.
Scientifically, very few tools are currently available for malaria control. For instance, we rely on only one class of antimalarial drug [the artemisinin-based combination therapies (ACTs)] to treat malaria patients. New drugs are of urgent need to support preventive strategies such as seasonal malaria chemoprevention and also to curve the resistance of the parasite to artemisinin derivatives that has emerged in South-East Asia and is spreading steadily in Africa.
The greatest tool that could make a huge contribution towards the malaria elimination will be a vaccine that has a protective efficacy over 75% as stated in the WHO malaria vaccine development road-map. Indeed, this will be instrumental in achieving malaria elimination in many parts of Sub-Saharan Africa where resources are limited to sustain the current expensive interventions for decades. However, only few malaria vaccine-candidates are reported in the pipeline. An inexpensive malaria vaccine that confers robust and long-term protection and is relatively simple to deploy is therefore highly desirable.
Concomitantly with the vaccine, malaria vector control in endemic settings is one the most important challenge that we have to overcome for malaria elimination. Therefore, we need to support the development of the newest mosquito control methods such as genetically modified mosquitos, or new insecticides.
There are also many other non-scientific challenges such as:
i) Securing funding to sustain the actual gains. This is particularly true in the context of the global Coronavirus pandemic and its impact on the fragile economy of our countries. For instance, the global investment of malaria control was estimated to be approximately US$ 3.0 billion in 2019, although US$ 5.6 billion are estimated to be required annually in order to reach the malaria control milestones in 2025.
ii) Sustaining public commitment toward malaria control interventions is also a real challenge. This is true for the local governments and communities.
iii) The progress reported in the 2020 World Malaria Report has been accomplished through mass active campaigns such as SMC, indoor residual spraying of insecticides and bed nets distribution. It is obvious that theses successful initiatives should be integrated into the routine health system in the long term perspective. The expanded programme on immunization is a perfect example of how to guarantee sustainable interventions through the routine health system.
iv) Finally, most West African countries have recently experienced some important troubles due to extremist groups’ attacks in the Sahel region. One of the immediate consequences has been the displacement of millions of people both within countries or regionally. How to secure effective coverage of the available malaria control interventions within these migrating populations is problematic.
Q: Despite the considerable progress made since 2000, the Global Technical Strategy 2020 milestones for 40% reduction in case incidence and mortality will not be achieved globally, and Burkina Faso, in particular, remains among the 10 countries with the highest number of malaria cases and deaths. How do you think the trends can be accelerated in high-burden countries to get closer to the 2030 targets?
HT: Burkina Faso is unfortunately among the countries with a high burden of malaria despite the observed global decline of the disease burden. To my opinion, the High Burden High Impact strategy is particularly suitable for countries like Burkina Faso. However, one of the key elements of success to accelerate the trends in high burden countries will be the ownership and the engagement of the countries’ governments to really invest (from their local budgets) the resources needed for malaria control activities rather than relying only on international donors’ generosity. The latter is very important in the current context of COVID-19, where the external resources are becoming scarce. There is also a need for a real community engagement (through intense communication) for a good adherence to control measures. In addition, if the ongoing pilot implementation of RTS,S malaria vaccine is successful, this vaccine should be deployed in the target age-groups in these countries as soon as possible. Finally, successful interventions such as SMC should be extended to children over 10 years of age, as a shift of severe malaria cases towards this age group is increasingly being reported in malaria-endemic settings.
Q: In 2009 you created the Clinical Research Unit of Nanoro (CRUN) in a rural area of Burkina Faso, where more than 25 trials have been conducted since then. Which are the key elements to succeed in conducting high-level research from resource-limited settings?
HT: Undoubtedly, it requires good and motivated collaborators and an exceptional funding opportunity from the start. In the case of the CRUN, the Institute of Tropical Medicine of Antwerp, the Malaria Clinical Trial Alliance (INDEPTH Network), together with the Malaria Vaccine Initiative (MVI) have been instrumental in providing the type of funding necessary to build up from almost scratch. However, the funding is not the only key element as you also need real leadership and vision on what you want today and where do you want to be in 10-20 years.
When I decided to build the CRUN in 2008 after my PhD, I had the objective to develop and maintain appropriate expertise and infrastructure ensuring high-quality clinical research and training. In fact, I had the vision to become a prominent research and training centre in sub-Saharan Africa, with the mission to provide evidence-based information for the health care of populations living in tropical countries, with a specific focus on malaria. This was achieved thanks to the excellent platform in full compliance with international standards that we were able to set-up in 2009.
One of the most important lessons learnt from the short history of the CRUN is that starting a new research unit requires a clear strategic development plan which includes a substantial place for the training of young scientists in an environment where they can get access to world-class training through collaborations and also the freedom to express their various talents when they are back home at the end of their training. Finally, building a good and trustful relationship with the community you are working with is a great paramount in enabling successful conduct of clinical trials.
Q: A report presenting 10 years of antimalarial drug efficacy and resistance was also published by WHO last month. Considering your experience in drug-resistance research, which next steps should be taken in this field and particularly in Africa?
HT: Most African countries are nowadays performing therapeutic efficacy studies routinely. The real missing capacity is the weak availability of the platform for genotyping of the PfK13 mutations. Therefore, an effort should be done toward a large implementation of the capacity to perform the molecular surveillance of Plasmodium falciparum resistance to ACT since the Pfkelch C580Y is now reported in Guinea Bissau and Pfkelch13 R561H in Rwanda.
In parallel, the development of new non-ACT-based antimalarial drug combinations with a shortened regimen (single or two doses) should be encouraged as this could make a great contribution to reduce the disease burden and circumvent the current ACT resistance problem.
Q: In your opinion, are there any lessons learnt from the COVID-19 pandemic response that the malaria community can take advantage of?
HT: On November 17th, 2020, Dr Francine Ntoumi wrote an excellent “World view” in Nature entitled “What if tropical diseases had as much attention as COVID?”. She depicted the challenges of not neglecting malaria research in the middle of a new life-threatening event.
A very important lesson learnt from the COVID-19 pandemic is the importance of the communication of the scientific knowledge to the general public and how to obtain public adherence to any disease control measures. Based on the polemics and rumours around the COVID vaccine, the malaria community should anticipate and develop clear and transparent messages towards the public about future vaccines and other Genetic modified mosquitoes. The last but not the least, we learnt as well from the COVID-19 pandemic that it is possible to have so important international mobilization and commitment of stakeholders, financial and political actors to face a disease. We think that malaria deserves the same attention and we hope that this will happen.
Q: As part of the malaria community, how do you foresee 2021?
HT: We are anxiously looking forward to seeing the impact of the COVID pandemic on the malaria burden and also its impact on the committed funding for malaria control programs and research. However, we hope that the world malaria elimination program will thrive despite the COVID 19 pandemic.
During the 2020 annual meeting of the American Society of Tropical Medicine and Hygiene, a team led by Prof Adrian Hill from the University of Oxford reported very exciting results of a Phase 2 trial of a malaria vaccine candidate R21 and has announced a plan for a phase 3 trial in 2021. During the same meeting, Sanaria Inc announced as well that phase 3 of the PfSPZ vaccine will start in 2021 which is another good news. Taken together, I think that 2021 will be a pivotal year for the malaria community as we will see the launch of game-changing two Phase 3 vaccine trials.
Professor Halidou Tinto, PharmD by background, worked from 1995 to 1999 as Research Associate at Centre Muraz, Burkina Faso, where he was involved in the epidemiological surveillance of malaria drug resistance. From 1999 to 2000, he worked at the Royal Danish School of Pharmacy, Denmark, as Research Fellow in the development of alternative medicines against malaria. From 2001, he was recruited to be a research associate at the Institute for Health Research (IRSS) and seconded at Centre Muraz. From 2003 to 2006, he worked as PhD fellow in Medical Sciences at the Institute of Tropical Medicine in Antwerp, Belgium, where he studied the epidemiology of malaria drug resistance in Burkina Faso and the mechanism of resistance in Rwanda. After obtaining his PhD in 2006, he returned to Burkina Faso where in 2008 he created a Clinical Research Unit. The unit has successfully conducted several trials including a malaria Phase III vaccine trial (RTS,S) and currently employs approximately 200 collaborators working on several research projects. He served as Scientific Director of Centre Muraz from 2013 to 2014 and recently as Regional Director of the IRSS in Nanoro in the Centre-West Region of Burkina Faso. In July 2016, he was graduated as Director of Research and Professor of Parasitology associated at the Nazi Boni University of Bobo-Dioulasso, Burkina Faso. He is the author and co-author of 186 publications in international peer-reviewed journals.