Equatorial Guinea Plays a Leading Role in Combating Malaria

In August 2014, I attended a ceremony at the Willard Hotel in Washington, DC that celebrated the tenth anniversary of the Bioko Island Malaria Control Project. Those speaking at the event included senior executives from Marathon Oil Corporation, Noble Energy Inc., and Atlantic Methanol Production Company, which are all US petroleum companies that operate in Equatorial Guinea. Teodoro Obiang Nguema Mbasogo, President of Equatorial Guinea, also delivered remarks.  

All of the speakers were enthusiastic about a dynamic project that has had a trans­formative effect on the health of generations of Equatoguineans by reducing the morbidity and mortality of malaria infection. What follows is an overview of the project’s history as well as the commitment to US innovation and a shared audacity to tackle one of human­kind’s most endemic and fatal diseases.

Malaria kills nearly 600,000 people worldwide every year. The disease is prevalent principally in countries around the equator in areas that include the Americas, many parts of Asia, and much of Africa. Eighty-five to ninety percent of these fatalities occur in Sub-Saharan Africa.  

Equatorial Guinea has a population of some 760,000 people, divided between the island of Bioko, where the capital of Malabo is located, and a Maryland-size portion of the country on the African mainland that is bordered by Cameroon and Gabon. Experts estimate that those who live in Equatorial Guinea are exposed to one of the highest rates of malaria infection in the world.

In Bioko, with a population of approximately 280,000, a 2004 study found that each year, every person on the island had an average of one suspected case of malaria, while children there often suffered multiple suspected cases of the deadly disease. The same study estimated that up to 60 percent of those on Bioko had the malaria parasite in their bloodstreams at any one point in time, and that 45 percent of children between the ages of two and 15 were infected. 

The Bioko Island Malaria Control Project is Launched

Beginning in the mid-1990s, following the discovery of offshore oil and gas near Bioko Island, US petroleum companies including Mobil Oil, the Hess Corporation, Marathon Oil Corporation, and Noble Energy began production activities. They established themselves as the major foreign investors in Equatorial Guinea, which is Sub-Saharan Africa’s third largest producer of oil and gas. Through their production sharing agreements, these US oil companies, and newer producers in Equatorial Guinea such as VAALCO Energy and Murphy Oil, maintain corporate social responsibility (CSR) programs that address development issues in the fields of education, health, sanitation, and environmental protection that are improving the lives of this country’s citizens.

In addition to their CSR programs, Marathon Oil Corporation, its production partner Noble Energy Inc., and co-owned methanol producer, Atlantic Methanol Production Company (AMPCO), have committed over $68 million between 2004 and 2018 to address the high incidence of malaria on Bioko Island. In 2004, they launched the Bioko Island Malaria Control Project (BIMCP) in collaboration with the Government of Equatorial Guinea. BIMCP’s 2004-2008 Phase I had a $14.5 million budget, two-thirds of which came from Marathon, Noble, and AMPCO, with the remaining third from Equatorial Guinea’s government.

After issuing a call for proposals, Marathon chose as the project’s technical imple­menter Medical Care Development International (MCDI), a US-based nongovernmental organization. MCDI had worked previously in Belize on a national anti-malaria project as well as on malaria prevention in various African countries with support from USAID-funded Child Survival Grants. 

The goal of the initial, four-year project was to bring about a substantial decline in malaria transmission and a reduction of fatalities, particularly among infants and children under the age of five. Preventive methods initially included mosquito vector control, public education, and enhanced diagnosis and treatment. A large number of Equatoguineans were hired and trained to eliminate mosquito breeding grounds. The BIMCP also used indoor resid­ual spraying (IRS), which entailed treating all vertical surfaces in houses and other build­ings. IRS had been used extensively, but then abandoned, by the World Health Organization (WHO) in the 1960s due to the health hazards presented by the use of DDT as well as the expense incurred via this type of intervention.

However, by 2004, with new, safer indoor insecticides and enhanced safety measures, IRS was re-introduced as an effective means to break the cycle of infected mosqui­toes spreading malaria. The health and safety of the sprayers and household inhabit­ants were monitored, with attention paid to informing residents of necessary precautions after indoor spraying, e.g. not entering the home for three hours after spraying and washing exposed cutlery and crockery. Protocols were developed and followed on the handling and storage of the insecticide and the supervised incineration of empty insecticide containers. This ensured that that environmental hazards were mitigated using WHO stand­ards during Equatorial Guinea’s rapid development curve during a time when the country’s govern­men­tal regulations were either lacking or inadequate.   

Diagnosis and treatment of those who came down with malaria were a major part of BIMCP’s efforts as well. In 2005, Equatorial Guinea became one of the first ten countries in Africa to offer those with malaria new WHO-recommended artemisinin-based combi­na­tion therapies (ACTs), that combine long- and short-term acting drugs, e.g. artesunate-amodiaquine or artemether-lumefantrine.

The aim was to overcome cases of malaria that were resistant to treatment by drugs such as chloroquine, as well as ensure that Equatorial Guinea was also adhering to WHO recommendations against artemisinin oral monotherapies that contribute to the emerging spread of artemisinin-resistant malaria. This combination therapy was originally offered free-of-charge to children under 15 and pregnant women. Pregnant women were also offered intermittent preventive therapy aimed at malaria prevention, as well as lowering the risk of neonatal and antenatal malaria transmission. 

Initial Results are Promising and the Campaign is Expanded to the Mainland

Within its first two years, BIMCP showed concrete, positive results: the number of malaria cases treated in government hospitals and clinics dropped from 55,000 in 2005 to 14,000 in 2006. In 2007, BIMCP also began an extensive campaign of distributing long-lasting, insecticide-treated bed nets throughout Bioko Island. In addition, the project launched an extensive information campaign utilizing not only mass media, but also trained community-based specialists who engaged in outreach activities to educate the public on safety precautions following indoor spraying, the proper use of bed nets, and the availability of malaria treatment. BIMCP also received additional funding from the United States Centers for Disease Control.

In 2006, the anti-malaria campaign in Equatorial Guinea got an especially big boost. The Global Fund to Fight AIDS Tuberculosis and Malaria provided a $26 million, five-year grant to employ the BIMCP model in combating malaria on Equatorial Guinea’s main­land, where two-thirds of its population live, and limited efforts were being made to control malaria. Marathon donated an additional $1 million to kick start anti-malaria work there.   

Good News 

By 2008, as Phase I of BIMCP was coming to an end, its success in combating malaria was overwhelmingly evident. The number of mosquitoes infected with the malaria parasite on Bioko Island was estimated to have dropped by 95 percent. More importantly, malaria infection in children between the ages of two and five had been reduced by half. In addition, the prevalence of the malaria-carrying parasite in children ranging in age from two to 14 had also been halved. 

However, there was much work left to be done. Phase II of BIMCP (2009-2013) began with a budget of $35 million, two-thirds of which came from Marathon, Noble, and AMPCO, and the remaining third from the Government of Equatorial Guinea. The goal of Phase II was to accelerate Phase I’s progress in controlling malaria. As noted above, during the first phase of the project, target groups had been given free-of-charge combined therapy for malaria. In 2010, Equatorial Guinea’s government began offering such free treatment at its medical facilities to all of Bioko’s residents. 

A Setback

Despite the many successes of both Phase I and Phase II, investigators encountered a serious setback in 2013. They found that the prevalence of malaria infections as well as the number of malaria cases treated at Bioko’s hospitals and clinics was increasing, with infection rates spiking to 28 percent in 2013, compared to a rate of 14 percent the year prior. BIMCP workers analyzed the data, and identified “hot spots” on the island where the rate of infection was particularly high. They responded by targeting these areas with a combination of methods including outdoor vector reduction, indoor spraying and distribu­tion of treated bed nets to reduce cases of malaria. They also noted that the increase in malaria infections in Equatorial Guinea was not an isolated phenomenon. Regionally there was a trend affecting malaria infection rates in Chad, the Central African Republic, and Ghana. This finding led to the belief that the issue was a natural cyclical increase rather than a location specific issue related to BIMCP efforts.   

Despite the setback, efforts to combat malaria continued. The partners committed private-public funding for another five-year cycle through 2018. These funds allowed the project to expand its use of long-lasting insecticide treated bed nets with the goal of reach­ing virtually all Bioko Island residents by 2015. In addition, environmental activities were implemented to support community-based campaigns to clean up rubbish, fill in areas of standing water, and cover water receptacles, and in urban communities, residents were taught how to use, and then supplied with, larvicide to control mosquito populations. Since 2013, progress has resumed in reducing the level of malaria infection, with the infection rate falling from 28 percent in 2013 to 19 percent in 2014.

I have been impressed by the variety of tools implemented, as well as the high cost of this project. BIMCP may be one of the most expensive malaria control programs in the world due to its use of robust monitoring and evaluation methods that measure infection rates in both human and mosquito populations. Despite this, the island was still experi­encing a disconcerting infection rate of nearly 20 percent.

Reviews of the data concluded that internal population movement between the mainland portion of Equatorial Guinea and the island resulted in a constant re-infection to Bioko. This movement consisted of those who resided for long periods on the mainland  before returning to Bioko Island. Such groups included soldiers on rotation, youth on vacation during school breaks, and citizens working in the informal economy and trading goods between the mainland and the island.

This challenge resulted in the US companies and the Government of Equatorial Guinea exploring alternative and effective tools that could not only protect people against malaria but also stop the transmission of the disease between human and mosquito populations. In 2014, the partners invested in what is potentially the most promising weapon in the anti-malaria arsenal: a new, anti-malaria vaccine now being tested in trials on Bioko Island.    

Anti-Malaria Vaccine Offers Hope for Equatorial Guinea and Beyond

For more than a decade, US biotechnology firm Sanaria has been working to develop a revolutionary, new vaccine against malaria. The vaccine, PfSPZ, is designed to prevent the disease’s transmission by attacking the malaria parasite before it can multiply rapidly in the liver, and cause blood stage malaria infection. If the vaccine is effective in blocking liver stage infection, then the vaccine has the potential, according to Sanaria’s founder, CEO and Chief Science Officer, Dr. Stephen Hoffman, of eventually eliminating the disease altogether by breaking the cycle of malaria infection between human and mosquito hosts.   

Based on this potential scientific breakthrough, the Government of Equatorial Guinea and its US corporate partners decided to fund trials of the new Sanaria vaccine in Equatorial Guinea. Before such trials could begin on Bioko Island, however, an infrastructure was needed in Equatorial Guinea that would meet all international standards for such testing. Working with Sanaria, the WHO’s Regional Health Office for Africa,  Tanzania’s Ifakara Health Institute, and MCDI, Equatorial Guinea’s Ministry of Health and Social Welfare established a national ethical review committee and a national regulatory authority. A first of its kind in Equatorial Guinea, it would study and design the protocols required to conduct anti-malaria vaccine trials on Bioko Island, as well as regulate and authorize the importation of experimental drugs and exportation of biological samples of human tissue.  

To pay for this new venture, now called the Equatoguinean Malaria Vaccine Initiative, Marathon, Noble, and AMPCO pledged $11.75 million, and the Government of Equatorial Guinea committed $36.75 million to fund three vaccine trials between 2015 and 2018, with the aim of having a United States Food and Drug Administration-approved product that will allow Bioko Island to be one of the world’s first endemic malaria zones to eradicate malaria from its population. 

In 2014, PfSPZ vaccine trials were already underway in the United States, Germany, Tanzania, and Mali, with all of them showing promising results. In March of this year, a safety trial with 33 volunteers was carried out at Malabo’s La Paz Hospital, the country’s premier health facility. Based on results of this trial, including proof of the vaccine’s safety, a 450 person trial will be conducted in 2016 and a 3,000 person proof of concept trial will be run in 2017 and 2018. 

Conclusion

A proven, effective means to prevent malaria still has not been found. However, there is no question in my mind that the unique public-private partnership initiated by US oil companies Marathon, Noble, and AMPCO, with the Government of Equatorial Guinea has saved countless lives in this country. Reduction in malaria infections, early diagnosis and effective treatment have also had health-enhancing benefits, especially for Equatorial Guinea’s youth. For more on the history of this fascinating project, I strongly recommend viewing the video “Hope for Bioko,” which is available at https://www.youtube.com/ watch?v=dfSP0YZ1TKY.

As United States Ambassador to Equatorial Guinea during the three past years, I have witnessed remarkable, pioneering work in this country to prevent and combat malaria, includ­ing the beginning of new vaccine trials. While I believe the Government of Equatorial Guinea needs to invest more in its people, particularly for primary health care, its strong support for the Bioko Island Malaria Control Project is noteworthy and commendable. What is happening here offers hope to the world that the global scourge of malaria may someday be eradicated.