Dr Richard Maude's work combines clinical studies, descriptive epidemiology and mathematical modelling of malaria in South and Southeast Asia. Over 1 million people die and 300-600 million suffer from malaria each year, and more than 40% of the world's population lives in malaria-risk areas. Understanding how to manage and treat malaria is therefore of vital importance, and achieving this aim needs a number of different approaches.
Malaria epidemiology focuses on two main challenges to malaria elimination: antimalarial drug resistance and the movement of people that are spreading the malaria parasite. Travel surveys and cellphone records, combined with population parasite genetics help predict the spread of malaria and of drug resistance. Close coordination with all groups and agencies involved is crucial to malaria surveillance and elimination strategies.
Ultimately, medical research must translate into improved treatments for patients. At the Nuffield Department of Medicine, our researchers collaborate to develop better health care, improved quality of life, and enhanced preventative measures for all patients. Our findings in the laboratory are translated into changes in clinical practice, from bench to bedside.
Richard Maude: We have several different projects. One of them at the moment: we’re working with 22 countries in Asia Pacific, contacting the malaria control programmes in each country. But we do more detailed work in Bangladesh, Thailand, Cambodia and Myanmar.
Q: Why the focus on those countries ?
RM: Those countries are of particular interest because of artemisinin resistance which has been relatively recently discovered and is a big threat to the elimination of malaria. Each of these countries has a plan to eliminate malaria but there is now a lot of resistance in Cambodia and it’s recently been found in Myanmar. There is a lot of concern that it could spread soon to Bangladesh.
Q: In malaria epidemiology, what is your main research focus and why is it important ?
RM: We study two of the main challenges to malaria elimination; this is a priority for this region, particularly in the Greater Mekong sub-region. Those main challenges are antimalarial drug resistance and the movement of people. The second problem is important because we are worried that people moving around both within and between countries are spreading the malaria parasite. Trying to control and eliminate malaria without understanding that is very difficult. At the moment we have field studies where we are doing travel surveys in lots of locations across the region. We are also collaborating with cellphone operators and the University of Harvard School of Public Health to use cellphone call detail records to look at population movement.
Q: That sounds pretty cutting edge. How does that work?
RM: It’s quite a new technique and potentially very powerful because it is individual records from people who make calls and send texts using mobile phones, and it covers an entire country. The resolution is potentially very high so you could zoom in to an area and see a lot details. We are also very interested in parasite genetics, studying population genetics, which means collecting blood samples from patients with malaria. One of our projects is to combine population parasite genetics with this travel movement data. By putting these together we hope to be able to predict and understand the spread of malaria and also the spread of drug resistance.
The artemisinins are the best antimalarials we have and our first line treatment worldwide for malaria. Artemisinin resistance was first identified in Cambodia in 2008-2009 when the evidence became very strong. Since then it’s been identified in a lot of other locations in South-East Asia. The worry is that if this first line treatment doesn’t work, then we are losing a very powerful tool for the elimination of malaria. Also if it doesn’t work so well people fail with their treatment and the infection comes back and they become sick again. We are very concerned that if this resistance spreads both across Asia and also outside into Africa and elsewhere, it will be a big threat to malaria control and elimination. The amount of malaria may increase and the number of deaths may well increase as well.
Q: What unique challenges do you face in your work?
RM: There are several. One of them is the simple problem that people with malaria are often not recorded in systems. In surveillance systems for national governments they have data from health facilities and maybe some international organisations that run clinics in the country. But a lot of people go to a shop or pharmacy and buy a treatment, and they are never recorded as being a case. This problem of trying to map where the cases are is very much driven by that. That is worse in more remote area where the risk of malaria is higher.
The other big challenge we have is the work we do has potentially very high impact on regional planning, and therefore it is very important to work very closely with all the international agencies that work on this, including WHO and also groups like Malaria Consortium and Population Services International. We try to coordinate very closely with these groups.
Q: What does malaria epidemiology matter and why we should fund it?
RM: In a sense it’s know thine enemy. Without properly understanding the epidemiology of malaria it's very hard to plan how to eliminate it. It is important to malaria surveillance and crucial to costing and also planning strategies for how to get rid of it. And that is the main drive in this region where we work.
Q: How does your work fit into translational medicine within MORU and Oxford?
RM: Within translational medicine in general, the work that we do is directly relevant to public health policy and planning. The research that we do is potentially heavily scrutinised by those that can act on the results. And finding, for example, the amount of malaria and determining the risk in a particuliar area – that has a very direct relevance to policy.