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Africa: Rolling Back Malaria?

AfricaFocus Bulletin
May 4, 2005 (050504)
(Reposted from sources cited below)

Editor's Note

The World Malaria Report 2005, a new comprehensive report released yesterday by the World Health Organization and UNICEF, clearly lays out the strategies needed to fight malaria, which kills at least one million people a year. But despite claiming progress in more widespread adoption of these strategies, the report also acknowledges that these measures are only beginning to have an effect. More skeptical observers, such as the medical journal The Lancet in an April 25 editorial, say that lack of resources and lack of capacity for implementation have in fact crippled the war against malaria.

Strategies documented as successful include switching to more effective (and more expensive) artemesinin-based drugs to replace older ineffective drugs, massive distribution of insecticidetreated bednets, and systematic indoor spraying of low-dose insecticides. But funding is only running at some $600 million a year, compared to a need for approximately $3.2 billion a year. Production of the new drugs is not meeting demand. And environmental concerns have curbed donor support for indoor spraying, although it has proved particularly effective in South Africa, Swaziland, and southern Mozambique (see

This AfricaFocus Bulletin contains excerpts from a press release and short briefing released with the World Malaria Report 2005. For the complete texts of the press release and briefing, as well as the full report, and other background information, see

The April 25 issue of the Lancet is available at

For an earlier AfricaFocus Bulletin on malaria, see

For additional news coverage on malaria, see

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

First global report on efforts to roll back malaria highlights progress and challenges

Burden of malaria still worst in Africa, but prevention and treatment reaching more people

Joint media release WHO/UNICEF

May 3, 2005

More people are accessing prevention and treatment services for malaria, sparking hope that the number of people who become sick and die from malaria will begin to decline. However, challenges remain to reduce the burden of the disease which still kills one million people every year, most of those in Africa, according to the 2005 World Malaria Report.

The report, released today by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), finds that progress has been made in preventing and treating malaria since 2000. It finds that more countries are introducing the newest medicines to treat malaria, and that more people are receiving long-lasting insecticide-treated mosquito nets through innovative new programmes. The report analyzes malaria data collected through 2004 and represents the most comprehensive effort ever made to present the available evidence on malaria worldwide.

"Many countries are moving forward with malaria control programmes, and even those with limited resources and a heavy malaria burden now have a better opportunity to gain ground against this disease," said Dr LEE Jong-wook, Director-General of WHO. "However, proven interventions such as insecticide-treated nets, and the latest artemisinin-based combination therapies must reach many more people before we can have a real impact on malaria."

Due to the difficulties involved in gathering reliable information about malaria in most affected countries and because those countries have intensified their efforts only in the past few years it is too soon to measure the impact on illness and death of the recent expansion of malaria control strategies, the report states. A measurable effect should become apparent about three years after widespread implementation.

A number of countries are now engaged in intense antimalarial campaigns. In particular, more and more people are protected with insecticide-treated nets - a highly effective method of malaria prevention. In Africa, all countries reporting on nets collectively had a 10-fold increase in the number of insecticide-treated nets distributed over the last three years.

After a 2003 campaign to distribute treated nets in five districts of Zambia at least 80% of children under five were sleeping under the nets. A similar campaign across Togo in December 2004 succeeded in raising the overall percentage of households owning at least one treated net from 8% to 62%. ...

Countries where the former mainstays of malaria treatment, such as chloroquine, are no longer effective are also moving forward on new therapies. Since 2001, 42 malaria-endemic countries, 23 of them in Africa, have adopted artemisinin-based combination therapies recommended by WHO. These are the latest generation of antimalarial medicines and the most effective treatment against falciparum malaria, the deadliest form of the disease. An additional 14 countries are in the process of changing their malaria treatment policy and 22 have embarked on home-care programmes which enable families and other care-givers to manage malaria.

The recent shortage of artemisinin-based combination therapies has hindered efforts to reduce the impact of the disease, but sufficient supplies to meet demand are expected to be available by the end of 2005, thanks to the combined efforts of UN agencies, other multilateral agencies, non-profit groups and corporations working together under the umbrella of the Roll Back Malaria Partnership.

The report finds that in 2003, some 350 to 500 million people worldwide became ill with malaria a slight revision of the estimate of 300 to 500 million annual cases that WHO has used since 2000. The reasons for this difference are advances in data collection methods and increases in the world's population. ... A major obstacle to achieving that goal [of halving the burden of malaria by 2010], the report explains, is a lack of funds. The report estimates that US$ 3.2 billion per year is needed to effectively combat malaria in the 82 countries with the highest disease burden. This year, US$ 600 million was made available for global malaria control. WHO and UNICEF welcome the recent World Bank announcement of its plan to commit US$ 500 million to US$ 1 billion over the next five years, which will help more people get access to essential malaria prevention and treatment.

A 5-minute briefing on the World Malaria Report 2005 from WHO and UNICEF

During the past 5 years real progress has been made in scaling up malaria control and prevention efforts Over 3 billion people live under the threat of malaria. It kills over a million each year -- mostly children. But the means to turn this tragedy into a global success story could now be made available to those in need.

Malaria. A disease so deadly it can kill within hours. And so prevalent that in some parts of the world there is barely a child who has not suffered by the time of his or her first birthday. Malaria kills over a million each year and some 3.2 billion people living in 107 countries or territories are at risk. But malaria is a curable disease. It is also a preventable disease.

The World Malaria Report 2005 represents the most comprehensive effort ever made to present the available evidence on malaria all around the globe. And it shows that during the past 4 or 5 years real progress has been made in the battle against this most devastating disease. For while overall trends are still hard to prove, the World Malaria Report 2005 presents clear evidence of successful control efforts that are having an impact on malaria in a large number of countries and territories throughout the world.

Rolling back malaria

A generation ago hopes were high that malaria could be eradicated. But the 1980s and early 1990s saw a tragic reversal of fortunes. The disease gathered new strength as the parasites developed resistance to the most commonly used antimalarial drugs, and the mosquitoes became resilient to insecticides. Economic upheaval, armed conflicts and complex emergencies also caused the breakdown of control programmes and the collapse of local primary health services. Determination and funds to fight the disease dried up and malaria once again tightened its grip on the poor and the vulnerable. In some parts of rural Africa south of the Sahara, child deaths from malaria increased by up to twofold during the 1990s while deaths from other causes were falling. Malaria also re-emerged in several Central Asian and Eastern European countries and in South-East Asia.

In response the Roll Back Malaria (RBM) Partnership was launched in 1998 by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank to bring together major stakeholders in the global fight against malaria. These include governments of malaria-endemic countries, donor governments, international

In the year 2000, African countries committed themselves to a series of malaria control targets to be reached by the end of 2005, chiefly protection through the use of ITNs for 60% of the people at highest risk and intermittent preventive treatment for 60% of pregnant women. Some countries have been able to reach or even exceed some of the targets. Most remaining countries are now poised to begin scaling up antimalarial efforts. A total of 23 African countries are now using the new and effective drugs (ACTs) and 22 have adopted the RBM-recommended strategy of home management of malaria for children under 5 years of age.

The number of ITNs distributed has increased 10-fold during the past 3 years in over 14 African countries. And surveys have shown remarkable increases in ITN coverage for children under 5 years of age in countries such as Eritrea and Malawi. But death rates are still high among those who fall ill and the vast majority of the death toll is among children under the age of 5. ...

Over 80% of malaria deaths occur in Africa where around 66% of the population are thought to be at risk. In contrast, less than 15% of the global total of malaria deaths occurs in Asia (including Eastern Europe), despite the fact that an estimated 49% of the people in this region are living under threat from the disease. In the Americas 14% of the population are at risk, but the region sees only a tiny fraction of global malaria-related deaths.

As these figures make clear, malaria exacts its heaviest toll on the African continent. Chiefly there are two explanations. First, the climate and ecology of tropical Africa provide ideal conditions for Anopheles gambiae the most efficient of the mosquitoes carrying the malaria parasite to thrive. And it is here also that Plasmodium falciparum the most deadly species of the malaria parasite is most common. This fatal combination greatly increases the transmission of malaria infection and the risk of disease and death. Second, poverty and lack of good-quality health care have hindered the control and treatment efforts that have had a significant impact elsewhere in the world.

Those most affected

A single bite from an infected mosquito is all it takes. A small child whose body is not yet able to fight the disease can be dead within a day. Pregnant women are highly vulnerable too. So is anyone whose defences are low as a result of poor health or who has no immunity because they have never, or only rarely, been infected with malaria. ...

Pregnant women who get malaria in some lower-risk areas are prone to anaemia, premature delivery and stillbirth; in other higher-risk areas they are more likely to suffer and die from anaemia and their babies are likely to be born too small to survive their first year of life. And all who fall sick -- with fever, headache and exhaustion -- are less productive and lose income because of absences from work or being too ill to plant and harvest crops. In effect, malaria tightens the shackles of poverty in the households, the communities and the nations where it holds sway.

We now have the tools

At the heart of the RBM approach is an understanding that malaria may never be wiped out once and for all. But the disease can and must be controlled.

The fight to control malaria demands an attack on two fronts: protecting the vulnerable and treating the sick. And it is essential that the measures used are affordable and sustainable so that they can continue to work far into the future.

Sleeping under a mosquito net treated with insecticides that kill mosquitoes or stop them from biting is powerful prevention against malaria, as is spraying inside dwellings with insecticides that leave a residue on walls. Special protection for pregnant women using these insecticide-treated nets (ITNs) and intermittent preventive treatment with antimalarial drugs given as part of normal antenatal care can protect the mother and her unborn child. Rapid treatment with effective antimalarial drugs for anyone suspected of having malaria can save lives. And improved early warning, detection and response to malaria epidemics can avert catastrophe.

The World Malaria Report 2005 documents the substantial progress that has been made in implementing these strategies on an increasingly wider scale. And, although it is too early to measure the precise impact of these efforts in terms of lives saved, there is good reason to believe that real reductions in deaths and disease will be achieved in the next few years. ...

Meeting the challenges in malaria control

The World Malaria Report 2005 also reveals the difficulties involved in the battle against malaria and shows the steps that are being taken to overcome them.

For example, drug resistance has been a serious obstacle to malaria control. Chloroquine, the cheapest and most widely used antimalarial drug, has lost its clinical effectiveness in most parts of the world. But the next generation of antimalarial drugs -- artemisinin-based combination therapies (ACTs) are highly effective and life saving. Work is under way to make these new drugs widely available, and more and more countries are changing their national drug policies and adopting ACTs as the first choice of treatment. However, while ACTs are available at between US$ 0.75 and US$ 2.75 per treatment, they are much more expensive than the drugs that previously worked. The higher cost puts ACTs beyond the reach of many of the households where the need is greatest. ...

Still, the formidable ability of the malaria parasite to develop rapid resistance to new drugs, and of the mosquitoes to become resistant to new insecticides, means that researching, developing and manufacturing new drugs and insecticides will continue to be of paramount importance. There is also now potential for an antimalarial vaccine, although this has proven more complex and is taking longer than expected.

Poverty is another major obstacle. One of the significant breakthroughs of recent years has been the mounting evidence that ITNs offer highly effective protection. But the effort to increase the numbers of children sleeping under ITNs has been hampered by the gap between what the nets cost and what families can and will pay for them. Now prices are being pushed down by increasing competition, cutting taxes and tariffs and distributing free-of-charge nets to the poor and most vulnerable. At the same time, demand is being increased by health education and marketing. The RBM partners are also working to encourage companies, especially in Africa, to manufacture the latest generation of treated mosquito nets that have insecticidal properties woven into the fabric and are longer-lasting. ...

The United Nations Decade to Roll Back Malaria 2001-2010

Malaria is a problem to which answers are available. The know-how, the plans and the technologies are all in place. And they are beginning to work. Just two things stand in the way of taking treatment and prevention measures to scale: a shortage of funds and a shortage of in-country capacity to put plans into action on the ground. This is the decade to take action: the time is now.

WHO estimates that around US$ 3.2 billion each year is required to finance effective malaria control worldwide. Governments in malaria-affected countries are committed to increasing their own resources for malaria control, and multilateral and bilateral donors have helped to provide extra money. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is also an important international funding source. But still the funds available fall far short of what is needed.

The drive to strengthen health systems, build organizational capacity and improve the infrastructure for supply and delivery on the ground in malaria-affected countries will also require commitment and cooperation between the global community and the local communities of people who live their lives under threat from the disease. ...

The RBM Partnership was launched against a disease that was rapidly gaining ground. The efforts made since then mean that this is no longer true. But the World Malaria Report 2005 makes it clear that fully reversing the trend is going to require more resources and more hard work in the years to come.

In the words of Professor Jeffrey Sachs, Director of the Earth Institute at Columbia University and Special Advisor to United Nations Secretary-General Kofi Annan, "Comprehensive malaria control is the lowest-hanging fruit on the planet. For just US$ 3 per person per year in the rich countries, it is possible to fund the comprehensive control of malaria in Africa, ensuring universal access to live-saving nets, effective medicines, and other control measures. Millions of lives in the coming years can be saved, with profound economic benefits as well. This is an historic bargain too great to miss."

"When I learned that malaria kills so many people just because they can't get simple medicine or a net to sleep under, I said, 'This is not possible, we must do something'." Youssou N'Dour, Musician, describing the motivation for Africa Live Roll Back Malaria Concert, Dakar, 12-13 March 2005

Prevention and treatment... the interventions that work

Insecticide-treated nets

ITNs protect people sleeping under them from malaria because they kill mosquitoes or prevent them from biting. Properly used, ITNs can cut malaria transmission by up to 90% and reduce child deaths from all causes by a fifth.

Protecting pregnant women

Intermittent preventive treatment a dose of an antimalarial medication given twice during pregnancy can be administered to pregnant women via antenatal clinics and can prevent malaria. Sleeping under an ITN can further protect pregnant women and their unborn children from the dangers of malaria.

Indoor residual spraying

Killing mosquitoes by spraying dwellings with insecticides that leave a residue on walls is a highly effective method for stopping the spread of malaria especially during epidemics and emergency situations.

Pre-empting epidemics

Sudden malaria epidemics can be foreseen using technologies such as weather forecasting and the regular collection of data from epidemic-prone districts. Predicting and then rapidly responding to epidemics can dramatically cut the number of cases.

Effective antimalarial drugs

Traditional antimalarial drugs have lost their clinical effectiveness as parasitic resistance has grown. But new generation artemisinin-based combination therapies (ACTs) are highly effective and life-saving in all but the most advanced cases.

Home management

Prompt treatment at home can mean the difference between life and death among people who live in rural areas and have limited access to health facilities. Home management of malaria which involves education and training of mothers and provision of prepackaged high-quality medicines allows families to care for their own children effectively.

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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