In 2016, there were 216 million malaria cases that led to 440,000 deaths. Of these about two thirds (290,000) were children under five years of age. This translates into a daily toll of nearly 800 children under age 5. Most of these deaths occurred in sub-Saharan Africa. Since 2010, mortality rates among children under five have fallen by 34 per cent.
Malaria is an urgent public health priority. Malaria and the costs of treatment trap families in a cycle of illness, suffering and poverty. Today, 3.2 billion (almost half of the world population) are at risk. Since 2000, malaria has cost sub-Saharan Africa US$ 300 million each year for case management alone and it is estimated to cost up to 1.3 per cent of GDP in Africa.
Despite this heavy toll, major inroads have been made against the disease as a result of stepped-up funding and programming. Between 2000 and 2010, global investment for malaria control increased significantly and domestic investments have also increased annually. Funding increases have resulted in major advances against malaria. However, success is fragile and closely tied to sustained support and since 2010 there has been a plateau in the funding of the global malaria response. In 2016, the global total of international and domestic funding for malaria control and elimination was $2.7 billion – less than half of what is needed. In order to achieve the goal of a malaria-free world, annual spending requirements needs to more than double from the current level to $6.4 billion by 2020.
PREVENTION
Sleeping under insecticide-treated mosquito nets (ITNs) on a regular basis is one of the most effective ways to prevent malaria transmission and reduce malaria related deaths. Since 2000, production, procurement and delivery of ITNs, particularly Long Lasting Insecticide Treated Nets (LLINs) have accelerated, resulting in increased household ownership and use. Since 2000, an estimated 1 billion ITNs have been distributed in Africa. Household ownership of ITNs/LLINs is uneven across countries in the region, with an average coverage of 66 per cent in sub-Saharan Africa – ranging from less than 30 per cent to approximately 90 per cent – but most countries have made considerable progress in the past decade. The proportion of sub-Saharan African households with at least one ITN increased to 67% in 2016, thus, a third of households where ITNs are the main method of vector control did not have access to a net. Additionally, only 42% of households had sufficient ITNs for all household members which is drastically short of the universal access of 100% to this preventive measure.
Over the last decade, the proportion of children sleeping under ITNs in sub-Saharan Africa increased from less than 5 per cent to nearly 50 per cent, with large country and regional variations. For instance, while the percentage in sub-Saharan Africa as a whole was 48 per cent in the 2011-2016 period, there are countries in the region with coverage below 25% while others have coverage around 80%. All countries with trend data have shown major increases in ITN use by children. Despite this progress, overall use of treated mosquito nets falls short of the global target of universal coverage, and many children are not benefiting from this potentially life-saving intervention. Over the past 5 years, an increase in the proportion of population with access to an ITN has resulted in an increased proportion of population at risk sleeping under an ITN. In sub-Saharan Africa, more than one-half of the population at risk slept under an ITN in 2017, increasing from 30% in 2010.
Most countries in Africa increased ITN use among children in an equitable way. This was largely due to free distribution campaigns that emphasized poor and rural areas. The success of this strategy has been reflected in an increased use of ITNs by vulnerable populations.
CASE MANAGEMENT
Until recently, the ‘proportion of children under 5 with fever who are treated with appropriate antimalarial drugs’ was the standard indicator for monitoring antimalarial treatment. However, it has become increasingly challenging to track trends following a 2010 WHO recommendation that advised universal use of diagnostic testing to confirm malaria infection before applying any treatment. As a follow up to this recommendation, many countries are now expanding the use of diagnostic testing to focus treatment on only those diagnosed with malaria. The current lower levels of antimalarial treatment in febrile children, therefore, may indicate that antimalarials are being provided only to confirmed cases. For more information on this issue, see the 2013 edition of the Household Survey Indicators for Malaria Control.
FIRST LINE TREATMENT
Artemisinin-based combination therapy (ACT) is the most effective antimalarial therapy for P. falciparum, the most lethal malaria parasite and the one most pervasive in sub-Saharan Africa. By the end of 2014, most African countries, where Plasmodium (P.) falciparum is endemic, had adopted ACTs as national policy for first-line treatment. However, in surveys since 2010, only a relatively small proportion of children treated for malaria were actually receiving ACT. Although the practice is changing, other less effective antimalarial drugs are still commonly used to treat malaria. Treatment of malaria in children with ACT is low in sub-Saharan Africa with just over one third of children treated with antimalarial drugs receiving the first-line drug. Lowest proportions – 21 per cent – are observed in West and Central Africa.
As per the 11 nationally representative household surveys conducted in sub-Saharan Africa between 2013 and 2015, the median proportion of children aged under 5-years with evidence of recent or current P. falciparum infection and a history of fever who received any antimalarial drug was 30%. The median proportion of children under 5 receiving ACT was much smaller, at around 14%. On the other hand, in case of children with both a fever in previous 2 weeks and a positive RDT at the time of survey, the proportion of antimalarial treatments that are ACTs has increased from a median of 29% in 2010-2011 to 80% in 2013-2015. Antimalarial treatments are more likely to be ACTs if children sought treatment at public health facilities or via community health workers than if they sought treatment in the private sector. However, no clear conclusions can be drawn from these findings because the ranges associated with the medians are wide, indicating large variation among countries; and, the household surveys cover only a third of the population at risk in sub-Saharan Africa.
MALARIA DURING PREGNANCY
In African countries with high malaria transmission, pregnant women are highly vulnerable to malaria infection due to reduced immunity. When infected with malaria during pregnancy, they are more likely to become anaemic and give birth to low-birthweight or stillborn babies.
- Pregnant women sleeping under ITNs – Regular use of ITNs by pregnant women as well as intermittent preventive treatment during pregnancy are vital interventions in the prevention of malaria among pregnant women. Although some progress has been made, the proportion of pregnant women in sub-Saharan Africa who sleep under an ITN is too low.
- Intermittent preventive treatment during pregnancy (IPTp) – Preventing malaria in pregnant women through IPTp with sulfadoxine-pyrimethamine, which is administered during antenatal care visits, is an effective way of reducing maternal anaemia and low birthweight. Nearly every country in sub-Saharan Africa with a high malaria burden has adopted intermittent preventive treatment for pregnant women as part of its national malaria control strategy. In most countries coverage of antenatal care services is much higher than current levels of IPTp administration, suggesting that there are missed opportunities to expand access to this life-saving intervention for mothers and newborns.
In October 2012, WHO issued a new recommendation that extended treatment at every antenatal visit to all pregnant women in areas of moderate-to-high malaria transmission. Many countries are still in the process of scaling up this new recommendation. However, according to the data for the previous recommendation (of at least two doses of sulfadoxine-pyrimethamine during antenatal care), very few countries have achieved relatively high coverage levels (50 to 70 per cent).
In 2016, only 13% of eligible women in sub-Saharan Africa received three or more doses of IPTp. The proportion of women receiving IPTp is varied across region, but all countries with coverage data between 2011-2016 indicated coverage at or below 50 per cent. Wealth and place of residence are major factors driving inequity in coverage of this important preventive treatment for pregnant women with higher coverage among women in the richest 20% of households and in urban areas compared to women in the poorest 20% of households and rural areas.
Download our latest infographic on “Investing in Malaria in Pregnancy in Sub-Saharan Africa: Saving Women’s and Children’s Lives“.
REFERENCES
UNICEF, Progress for Children Beyond Averages: Learning from the MDGs, New York, 2015
Measure Evaluation, Measure DHS, President’s Malaria Initiative, Roll Back Malaria Partnership, UNICEF and WHO, 2013 Household Survey Indicators for Malaria Control.
President’s Malaria Initiative, 2014, Eighth Annual Report to Congress, Washington DC, April 2014.
Roll Back Malaria Partnership, A Decade of Partnership and Results, Progress & Impact Series, Report no. 7, WHO, Geneva, September 2011.
UNICEF, The State of the World’s Children 2015, UNICEF, New York, 2015.
WHO, Guidelines for the Treatment of Malaria: Second edition, WHO, Geneva, 2010.
WHO, World Malaria Report 2014, WHO, Geneva, 2013.
