AFRICA MALARIA REPORT 2003
October 1998, together with the President of the World Bank
and the Administrator of the United Nations Development
Programme, we launched Roll Back Malaria as a catalyst for a
renewed global commitment to tackle a disease that has been
ignored by the world for far too long - a single disease that
puts a brake on development, particularly in Africa.
report from UNICEF and WHO suggests that, in 2003, malaria
remains the single biggest cause of death of young children in
Africa and one of the most important threats to the health of
pregnant women and their newborns. However, there are clear
signs that the movement to Roll Back Malaria is having an
impact. The combined strategies suggested in 1998 for reducing
the burden of malaria (insecticide-treated nets, prompt access
to treatment, and prevention of malaria in pregnancy) are now
widely accepted; their application on a large scale throughout
Africa is under way.
coverage of individual interventions, such as
insecticide-treated nets, is still far too low, the good news
is that there is a clear trend towards increasing coverage,
and other encouraging moves - a change in government taxation
nets and netting materials, for example, and the development
of Africa-based industrial production of nets - that will help
sustain this trend.
resistance to previously effective low-cost drugs is an
enormous and growing problem, but governments are now fully
engaged in this challenge, monitoring the development of
resistance and energetically pursuing the most promising
options for more effective treatment.
financial resources for fighting malaria are increasing. The
establishment of the Global Fund to Fight AIDS, Tuberculosis
and Malaria is providing significant new grants to help
countries accelerate implementation of their plans to Roll
Back Malaria. In addition, funds made available to improve
health under debt-relief initiatives are being used to finance
malaria interventions in some countries.
two organizations remain firmly committed to working together,
with our other partners and with Africa, to achieve the
ambitious goals for Roll Back Malaria set in Abuja on 25 April
2000 and agreed to by African heads of state. We intend that
this report should be the first of a regular series, tracking
progress towards achievement of these goals and of the
Millennium Development Goal for malaria.
United Nations Children's Fund
Dr Gro Harlem Brundtland
World Health Organization
report - the first of its kind - takes stock of the malaria
situation and of continuing efforts to tackle the disease in
Africa; it is based on a review of the best information
available to WHO and UNICEF, from sample surveys and routine
reports, at the end of 2002.
continues to be a major impediment to health in Africa south
of the Sahara, where it frequently takes its greatest toll on
very young children and pregnant women. Because malaria is
such a common disease and well known to the people it affects
most, and because many of those who become sick with malaria
do not visit health care facilities, assessing the size of the
problem, and how it is changing over time, is an enormous
analyses confirm that malaria is a principal cause of at least
one-fifth of all young child deaths in Africa. The latest
available data on outpatient visits and on hospital admissions
and deaths due to malaria confirm that this disease makes
substantial demands on Africa's fragile health infrastructure.
In endemic countries, as many as one-third of all clinic
visits and at least a quarter of all hospital admissions are
for malaria. In some countries, these data suggest that
illness due to malaria has increased over the past decade; in
others, the size of the problem has remained constant. No
country in Africa south of the Sahara for which data are
available shows a substantial decline.
information on trends in malaria mortality is available for an
increasing number of countries with "demographic
surveillance systems". These sources indicate that the
number of children dying of malaria rose substantially in
eastern and southern Africa during the first half of the past
decade compared with the 1980s. In west Africa over the same
period there was little change in the overall malaria
mortality rate in children.
summary, the burden of sickness and death due to malaria
remained high in Africa south of the Sahara during the 1990s
and increased in most countries in the eastern and southern
part of the continent. Monitoring systems cannot yet reliably
track changes in indicators of the burden of malaria,
particularly malaria mortality, on a yearly basis.
high burden of malaria in Africa, and the increasing burden in
some parts of the continent during the 1990s, is not an
indication that the intensified efforts to control the disease
over the past few years have had no impact. The full impact on
malaria sickness and death of the recent efforts to accelerate
malaria control described in this report will be measurable
only some years after high coverage of interventions is
achieved. It is possible that the start of intensified control
efforts coincided with increasing malaria mortality, meaning
that - without them - the situation might have been
substantially worse than is now reported. The strengthening of
malaria surveillance and monitoring needs to be given priority
in parallel with efforts to control malaria.
2000 Summit on Roll Back Malaria, held in Abuja, endorsed a
"shortlist" of relatively inexpensive malaria
control interventions already available and known to be
effective. Partners in the Roll Back Malaria effort, which
include governments of malaria-endemic countries, donor
governments, international organizations, the private sector,
and civil society bodies, have supported the introduction of
nets (ITNs) are a low-cost and highly effective way of
reducing the incidence of malaria in people who sleep under
them, and they have been conclusively shown in a series of
trials to substantially reduce child mortality in
malaria-endemic areas of Africa. By preventing malaria, ITNs
reduce the need for treatment and the pressure on health
services, which is particularly important in view of the
increase in drug-resistant falciparum malaria parasites.
Although accurate data from the 1980s are not generally
available for comparison, it is certain that there are now
more children sleeping under nets and a greater use of ITNs in
Africa than ever before. Recent survey data showed that
approximately 15% of young children slept under a net, but
that only about 2% used nets that were treated with
insecticide. Untreated nets provide some protection against
malaria, but their full protective benefits can be realized
only if they are regularly retreated with insecticide.
price of nets has fallen substantially as a result of greater
demand, increased competition between producers, and
reductions in taxes and tariffs and other obstacles to trade
that many African countries instituted after the Abuja Summit.
In many countries, both nets and the insecticide to treat them
can now be purchased in small shops and markets and even on
street corners; only a few years ago they would have been
available only in a few specialist shops in capital cities. At
least five large factories in Africa are now producing nets.
Almost all malaria-endemic African countries now have active
programmes under way to encourage ITN use, and most of these
support a variety of different mechanisms to increase net
coverage. Nevertheless, the commercial price of nets and
insecticide - though falling - still puts this life-saving
technology beyond the reach of the poorest income groups of
the population. Major efforts are now being made in at least
five African countries to provide subsidized ITNs to the most
vulnerable groups - young children and pregnant women. New
technological developments promise nets that will retain
insecticidal activity for many years, and novel ways of
encouraging regular net treatment with insecticide should make
it possible to increase the proportion of nets that are
nets and other means of reducing mosquito bites will not
totally prevent malaria. People who become ill with the
disease need prompt and effective treatment to prevent the
development of severe manifestations and death. Since the
1980s, parasite resistance to chloroquine, the most commonly
available antimalarial drug, has emerged as a major challenge.
In most countries in eastern, central, and southern Africa,
chloroquine has lost its clinical effectiveness as a malaria
treatment. A similar evolution is taking place, though some
years later, in west Africa, and there is indirect, but
compelling, evidence that this is giving rise to increasing
mortality. Unfortunately, resistance to the most common
replacement drug, sulfadoxine-pyrimethamine, has also emerged,
especially in eastern and southern Africa.
the past few years, 13 countries in Africa have changed their
national policies to require the use of more effective
antimalarial treatments. Where current monotherapies are
failing, WHO recommends artemisinin-based combination therapy
(ACT), which is highly efficacious and promises to delay the
emergence of resistance. So far however, its use is
constrained by high costs and limited operational experience
in Africa. To date, four African countries have adopted ACTs
as first-line treatment.
management of malaria cases may be undertaken as part of a
general strengthening of public health services, for example
as part of the strategy for Integrated Management of Childhood
Illness (IMCI). However, in many malaria-endemic countries the
first treatment for malaria is often purchased from a shop.
Data from representative sample surveys indicate that almost
half of all children under 5 years of age with fever are
treated with an antimalarial drug. Although this is
encouraging, some of these treatments may have been with
failing drugs or been given too late or in the wrong dosage.
Recent studies indicate that home treatment, supported by
public information and pre-packaging (as an aid, to ensure
that patients take the full treatment course at the right
time), can help to reduce malaria mortality in children. Many
countries now concentrate on making effective malaria
treatment available close to the home, through support to
community initiatives and engagement of drug sellers and the
pharmaceutical industry. Realizing the full potential of
effective treatment as a tool for reducing mortality will
require a systems approach, ensuring that effective drugs are
affordable (which will often require subsidization) and that
they are supported by appropriate education of formal and
informal providers as well as mothers, and by quality
assurance and regulation.
impact of malaria on pregnant women and their newborns can be
substantially reduced by the recently recommended use of
"intermittent preventive treatment" (IPT). This
strategy provides at least two treatment doses of an effective
antimalarial at routine antenatal clinics to all pregnant
women living in areas at risk of endemic falciparum malaria in
Africa (irrespective of whether they are actually infected
with malaria or not). About two-thirds of pregnant women in
Africa south of the Sahara attend clinics for antenatal care,
and incorporating IPT for malaria into their routine care
should be straightforward. Now an integral part of the
"Making Pregnancy Safer" strategy, IPT has been
adopted as policy by six countries to replace chemoprophylaxis;
most other countries in the region are reviewing their
policies in the light of the new recommendation. The
beneficial effects of IPT will probably be additive to the
proven benefits of ITN use by pregnant women. A comprehensive
approach to the prevention and management of malaria during
pregnancy therefore calls for a combination of IPT, support
for ITN use, and prompt access to effective treatment. Five
countries in eastern and southern Africa have recently formed
a coalition to reduce the impact of malaria in pregnancy
through this combined approach.
on the northern and southern fringes of the malaria-endemic
belt of Africa, as well as highland areas in many countries,
are at risk of epidemic malaria. Unlike the endemic disease,
epidemic malaria typically affects people of all ages and can
have high case-fatality. Roll Back Malaria has been supporting
efforts to improve the early recognition of, and effective and
timely response to, malaria epidemics. Indoor residual
spraying can play an important role in malaria vector control,
especially in the control of epidemics. Malaria early warning
systems have been established in southern Africa to improve
outbreak detection and response and are being developed in
other epidemic-prone parts of Africa. Fifteen epidemic-prone
countries have developed a preparedness plan of action; data
on the timeliness and effectiveness of epidemic response in
these countries are presented in this report.
malaria effectively requires substantial resources. At the
Abuja Summit it was estimated that at least US$ 1 billion is
needed from a combination of increased domestic spending and
international assistance; the report provides information on
resource flows. Since the launch of Roll Back Malaria in 1998,
international spending on malaria has more than doubled to
approximately US$ 200 million per year. Further untapped
resources for malaria control may become available through
debt relief initiatives. Government spending on all health
care is low in most African countries - typically less than
US$ 15 per person per year - and the costs of malaria control
are high: artemisinin-based combination drugs to treat
resistant malaria are likely to cost US$ 1-3 per treatment for
the drug alone, and ITNs cost around US$ 5. Most of the costs
of preventing and treating malaria in Africa today are in fact
borne by people themselves. For example, people buy nets,
insecticide sprays, and coils, and spend a considerable amount
of money on malaria treatment, which may contribute to
poverty. Increasing the efficiency of domestic "out of
pocket" spending is a priority, and this can be achieved
through government support for the most effective
interventions and the appropriate regulation to ensure that
only safe, effective malaria interventions are sold and that
the public is fully informed about their use and
recently established Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM) is a major new source of grant funding for
tackling malaria in Africa. Twenty-five countries and one
multi-country group have submitted successful proposals to the
GFATM. Almost all of these proposals build on the national
malaria control plans developed by these countries with the
support of the Roll Back Malaria Partnership during the period
1999-2001. The countries have been awarded a total of US$ 256
million for an initial two years to scale up malaria control
activities. Depending on success, it is expected that
additional funds will be made available for a total period of
report has been drafted in response to a seemingly very simple
question: "What do we know about malaria in Africa
today?" In the past, the answer to this question would
have been, "It depends on whom you ask." Although
most experts would have agreed on the fundamental facts,
including the relative importance of the disease, its
geographical distribution, and the key strategies for
prevention and treatment, opinions would have begun to diverge
at the next level of detail - dictated by personal experience
in the absence of routinely collected and authoritative
information on the global malaria situation.
statistics on malaria in Africa have been difficult to collect
and report because of the enormity of the disease problem, the
weakness of health information systems, and the fact that
treatment of most malaria cases, as well as many deaths from
the disease, occurs outside the formal health system.
Following the period of international indifference to malaria,
there was also little international agreement on what
information was needed for monitoring malaria control and how
it should be collected. This situation is changing, and there
is now a strong consensus on priority indicators and the best
way of collecting representative information.
the 1950s and 1960s, the malaria eradication campaign
successfully eliminated or controlled the disease in countries
with temperate climates and in some countries where malaria
transmission was low or moderate. However, the emergence of
drug and insecticide resistance, coupled with concerns about
the feasibility and sustainability of tackling malaria in
areas with weak infrastructure and high transmission, brought
an end to the eradication era, as well as to the bulk of
international funding for malaria control and investment in
malaria research. Despite international indifference in
subsequent years, progress continued to be made in
understanding the problem of malaria and strategies for its
control. By the early 1990s the international community began
to appreciate that the malaria burden was unacceptably high
and worsening, particularly in Africa, and that real
reductions in malaria mortality and morbidity were possible
with existing but under-used tools and strategies.
1992, malaria control was re-established as a global health
priority by a Conference of Ministers of Health held in
Amsterdam. Scientific interest in the disease and its control,
political commitment to reducing the burden of malaria, and
the financial resources for malaria research and control began
to increase rapidly. The project for Accelerated
Implementation of Malaria Control (1997-1998) represented an
unprecedented contribution to the fight against malaria in
Africa south of the Sahara, in terms of both technical support
and funds. The funding provided for the project over the two
years was estimated to have been more than 12 times the
contributions made by WHO during the previous decade.
the year 2000 a sequence of critical milestones had been
achieved and an ambitious global commitment had been realized:
- 1991-1998: malaria
control expertise and capacity were expanded and
strengthened, particularly in Africa, especially through
the project for Accelerated Implementation of Malaria
- 1997: new research
collaborations, notably the Multilateral Initiative on
Malaria (http://mim.nih.gov/), were formed.
- 1998: the Roll Back
Malaria Partnership (www.rbm.who.int/) was launched and
consensus on the core technical strategies for tacking
- 2000: the United Nations
declared 2001-2010 the Decade to Roll Back Malaria in
developing countries, particularly in Africa (United
Nations General Assembly, Resolution 55/284).
- 2000: malaria figured
prominently in the United Nations' Millennium Development
Goals (General Assembly official records: 27th Special
Session: Supplement 3. Document A/S-27/19/Rev.1).
- 2000: African heads of
state met in a historic summit in Abuja, Nigeria, to
express their personal commitment to tackling malaria and
to establish targets for implementing the technical
strategies to Roll Back Malaria.
- 2001: resources for
controlling malaria were significantly boosted with the
establishment of the Global Fund to Fight AIDS,
Tuberculosis and Malaria.
With the renewed international commitment to
fighting malaria, the need for regular and reliable
information on the global malaria situation is greater than it
has ever been. The general indifference of the past has given
way to an urgent demand for information that can be used to
define and analyse the malaria situation and measure progress
towards the goals established by the international community
and by national control programmes. The World Health
Organization (WHO) and the United Nations Children's Fund
(UNICEF) are committed to meeting this demand.
This report is an initial effort to collect,
analyse, and present information on the malaria situation. The
report focuses on Africa and specifically on those African
countries with the highest burden of the disease. These
countries bear more than 90% of the global malaria burden.
Emphasis is also given to the technical strategies for malaria
control established by the Roll Back Malaria Partnership and
the targets set at the Abuja Summit. In addition, with due
regard to the importance of understanding the resource
requirements of malaria control, a chapter on resource
mobilization and financing is included.
The data contained in this report have been
drawn from a variety of sources in order to provide the most
complete picture of the malaria situation in Africa. The
UNICEF Multiple Indicator Cluster Surveys and the and Health
Surveys, in particular, are national surveys that represent a
major advance in collection of baseline data to provide
benchmarks against which progress can be measured. It is fully
expected that the recent consensus on core data needs, well
coordinated efforts to collect data, and progress in solving
methodological and other data collection problems will
together fulfil the new demands for malaria information.
The goal of Roll Back Malaria is to halve the
burden of malaria by 2010. The following targets for
specific intervention strategies were established at the
Abuja Malaria Summit, April 2000
Abuja target (by 2005)
Prompt access to effective treatment
· 60% of those suffering with malaria should have access to
and be able to use correct, affordable, and appropriate
treatment within 24 hours of the onset of symptoms
Insecticide-treated nets (ITNs)
of those at risk for malaria, particularly children
under 5 years of age and pregnant women, will benefit
from a suitable combination of personal and community
protective measures, such as ITNs
Prevention and control of malaria in pregnant
of pregnant women at risk of malaria will be covered
with suitable combinations of personal and community
protective measures, such as ITNs
of pregnant women at risk of malaria will have access to
intermittent preventive treatmenta
Malaria epidemic and emergency response
of epidemics are detected within 2 weeks of onset
of epidemics are responded to within 2 weeks of
a: The original Abuja declaration included
the recommendation for chemoprophylaxis as well, but
present WHO and RBM policy strongly recommends IPT - and
not chemoprophylaxis - for prevention of malaria during
the left is a normal, healthy, red blood cell with a
smooth surface. The flexible and deformable disc shape
allows it to flow easily through narrow blood
the right is a similar red blood cell infected for one
day with Plasmodium falciparum parasites. It
has many knob-like protrusions.
cell's rapid transformation to a more rigid spherical
shape impedes flow through narrow blood capillaries.
Additionally the protrusions act like Velcro, causing
the infected blood cell to bind to specific receptors
such as those on the lining of blood vessels. These
adhesions in the brain and the placenta are part of
the cause of cerebral and placental malaria.
from scanning electron microscope: Lirong Shi, Michael
Delannoy, David Sullivan, Johns Hopkins Bloomberg
School of Public Health, Malaria Research Institute
1. THE BURDEN OF MALARIA IN AFRICA
90% of all malaria deaths in the world today occur in Africa
south of the Sahara. This is because the majority of
infections in Africa are caused by Plasmodium falciparum, the
most dangerous of the four human malaria parasites. It is also
because the most effective malaria vector - the mosquito
Anopheles gambiae - is the most widespread in Africa and the
most difficult to control. An estimated one million people in
Africa die from malaria each year and most of these are
children under 5 years old (1).
affects the lives of almost all people living in the area of
Africa defined by the southern fringes of the Sahara Desert in
the north, and a latitude of about 28° in the south. Most
people at risk of the disease live in areas of relatively
stable malaria transmission - infection is common and occurs
with sufficient frequency that some level of immunity
develops. A smaller proportion of people live in areas where
risk of malaria is more seasonal and less predictable, because
of either altitude or rainfall patterns. People living in the
peripheral areas north or south of the main endemic area
(Figure 1.1) or bordering highland areas are vulnerable to
highly seasonal transmission and to malaria epidemics.
areas of stable malaria transmission, very young children and
pregnant women are the population groups at highest risk for
malaria morbidity and mortality. Most children experience
their first malaria infections during the first year or two of
life, when they have not yet acquired adequate clinical
immunity - which makes these early years particularly
dangerous. Ninety percent of all malaria deaths in Africa
occur in young children. Adult women in areas of stable
transmission have a high level of immunity, but this is
impaired especially in the first pregnancy, with the result
that risk of infection increases.
has been well controlled or eliminated in the five
northernmost African countries, Algeria, Egypt, Libyan Arab
Jamahiriya, Morocco, and Tunisia. In these countries the
disease was caused predominantly by Plasmodium vivax and
transmitted by mosquitoes that were much easier to control
than those in Africa south of the Sahara. Surveillance efforts
continue in most of these countries in order to prevent both a
reintroduction of malaria parasites to local mosquito
populations, and the introduction of other mosquito species
that could transmit malaria more efficiently (a particular
risk in southern Egypt). The malaria situation in these
countries is not considered further in this report.
is endemic in some of the offshore islands to the west of
mainland Africa - Sao Tome and Principe and Săo Tiago Island
of Cape Verde. In the east, malaria is endemic in Madagascar,
in the Comoro islands (both the Islamic Federal Republic of
the Comoros and the French Territorial Collectivity of Mayotte),
and on Pemba and Zanzibar, but has been eliminated from the
island of Reunion. In Mauritius, malaria has been well
controlled since the 1950s, but occasional outbreaks of vivax
malaria occur, the last in association with a cyclone in 1982.
Since that year there has been a steady decrease in cases and
risk is now extremely low. Seychelles has been free of malaria
since 1930, and malaria vectors are believed to no longer
Burden of malaria on health in Africa
are three principal ways in which malaria can contribute to
death in young children (Figure 1.2). First, an overwhelming
acute infection, which frequently presents as seizures or coma
(cerebral malaria), may kill a child directly and quickly.
Second, repeated malaria infections contribute to the
development of severe anaemia, which substantially increases
the risk of death. Third, low birth weight - frequently the
consequence of malaria infection in pregnant women - is the
major risk factor for death in the first month of life (3). In
addition, repeated malaria infections make young children more
susceptible to other common childhood illnesses, such as
diarrhoea and respiratory infections, and thus contribute
indirectly to mortality (4).
consensus view of recent studies and reviews is that malaria
causes at least 20% of all deaths in children under 5 years of
age in Africa (Figures 1.3 and 1.4). Although respiratory
disease caused by a variety of infectious agents results in a
similar proportion of deaths, P. falciparum is the most
important single infectious agent causing death among young
and long-term disability
who survive malaria may suffer long-term consequences of the
infection. Repeated episodes of fever and illness reduce
appetite and restrict play, social interaction, and
educational opportunities, thereby contributing to poor
development. An estimated 2% of children who recover from
malaria infections affecting the brain (cerebral malaria)
suffer from learning impairments and disabilities due to brain
damage, including epilepsy and spasticity (5).
Burden of malaria on African health systems
all malaria-endemic countries in Africa, 25-40% (average 30%)
of all outpatient clinic visits are for malaria (with most
diagnosis made clinically). In these same countries, between
20% and 50% of all hospital admissions are a consequence of
malaria (see country profiles for details).
high case-fatality rates due to late presentation, inadequate
management, and unavailability or stock-outs of effective
drugs, malaria is also a major contributor to deaths among
hospital inpatients (Figure 1.5).
high burden may in fact be partly a result of misdiagnoses,
since many facilities lack laboratory capacity and it is often
difficult clinically to distinguish malaria from other
infectious diseases. Nonetheless, malaria is responsible for a
high proportion of public health expenditure on curative
treatment, and substantial reductions in malaria incidence
would free up available health resources and facilities and
health workers' time, to tackle other health problems.
Burden of malaria on the poor
people are at increased risk both of becoming infected with
malaria and of becoming infected more frequently. Child
mortality rates are known to be higher in poorer households
and malaria is responsible for a substantial proportion of
these deaths. In a demographic surveillance system in rural
areas of the United Republic of Tanzania, under-5 mortality
following acute fever (much of which would be expected to be
due to malaria) was 39% higher in the poorest socioeconomic
group than in the richest (6).
survey in Zambia also found a substantially higher prevalence
of malaria infection among the poorest population groups (7)
(Figure 1.6). Poor families live in dwellings that offer
little protection against mosquitoes and are less able to
afford insecticide-treated nets. Poor people are also less
likely to be able to pay either for effective malaria
treatment or for transportation to a health facility capable
of treating the disease.
direct and indirect costs associated with a malaria episode
represent a substantial burden on the poorer households. A
study in northern Ghana found that, while the cost of malaria
care was just 1% of the income of the rich, it was 34% of the
income of poor households (8).
Recent trends in the burden of malaria
case detection and reporting
from health facilities are potentially useful for monitoring
time trends in the number of malaria cases and deaths but have
severe limitations (Figure 1.7). In Africa, most cases of
malaria are diagnosed on the basis of clinical symptoms and
treatment is presumptive, rather than based on laboratory
confirmation. Moreover, malaria parasitaemia is common among
clinic attendees in many endemic areas, so that a positive
laboratory result does not necessarily mean that the patient
is ill with malaria. The main clinical symptoms of malaria -
fever and general weakness - are nonspecific and may well be
due to other common infections.
from facilities to districts and from districts to the
ministry of health varies in its completeness and timeliness
from country to country and often does not include
nongovernment facilities. Thus, routine reports of the number
of malaria cases and deaths have limited value for comparisons
of the malaria burden between countries. Demographic and
health surveys (DHS) and other sources (9) indicate that less
than 40% of malaria morbidity and mortality is seen in formal
health facilities - a small fraction of the total burden.
However, routinely collected data are often the only
information available over a prolonged period and over a wide
geographical area. While these data are of use for local
programme planning, major investment in improving both the
quality of health information systems and access to health
services would be required before their utility for monitoring
changes in malaria disease trends could be assessed.
present, the most reliable data available on trends in malaria
deaths in children under 5 years of age is obtained from
demographic surveillance systems (DSS), which measure deaths
and possible causes prospectively over time in populations of
known size and composition. The number of DSS sites is
increasing: 24 sites in 13 African countries are collaborating
under the INDEPTH network (International Network of field
sites with continuous Demographic Evaluation of Populations
and Their Health) (10). Most of these sites are in eastern and
southern Africa; there are a few sites in the west of the
continent but none in central Africa.
data from 1982-1998 were analysed across 28 DSS sites,
adjusting for the specificity and sensitivity of verbal
autopsies that were used to attribute deaths to malaria (11).
Malaria mortality in under-5s almost doubled in eastern and
southern Africa over the period 1990-1998 compared with
1982-1989. It is known that the prevalence of malaria
infections caused by chloroquine-resistant parasites increased
substantially from the late 1980s in these same areas (Figure
1.8). Thus, although the methodology cannot prove cause and
effect, it is very likely that some of this increase in child
mortality was related to some extent to the spread of
chloroquine-resistant malaria. In west Africa the mortality
rate remained the same; here too, however, malaria became
proportionally more important (11). Analysis of mortality data
being collected from INDEPTH using standardized verbal autopsy
questionnaires since 2000 should soon provide further insight
into more recent disease trends.
Africa south of the Sahara, the decrease in all-cause under-5
mortality that was apparent during the 1970s and 1980s
levelled off in the 1990s (Figure 1.9), perhaps partially as a
result of increased malaria mortality. Some of the important
factors that may have contributed to the increasing malaria
burden in these African settings include:
- drug resistance (12)
- more frequent exposure
of non-immune populations
- emergence of HIV/AIDS
- climate and
environmental change (15)
- breakdown of control
1.5 Future prospects
From the time trends shown, it appears that RBM
is acting against a background of increasing malaria burden.
With the typical 2-3-year delay in national-level data
becoming available, it is still too early to evaluate the
extent to which RBM has achieved a levelling-off or reversal
of the rising trend in the malaria burden. The very low level
of coverage with ITNs and untreated nets documented in 2000
and 2001 falls far below the coverage levels in the ITN trials
that demonstrated substantial health benefits. It should
therefore come as no surprise that significant reductions in
child mortality have yet to be observed. The impact of
treatment coverage levels is more difficult to estimate, given
both a lack of information on promptness and dosage, and
varying levels of drug effectiveness. Coverage levels
approaching the Abuja target of 60% will probably be required
before the full effect of ITNs and effective treatment on
child health will become apparent.
1. The World Health Report 2002: reducing
risks, promoting healthy life. Geneva, World Health
2. MARA/ARMA collaboration (Mapping Malaria
Risk in Africa), July 2002. www.mara.org.za.
3. Steketee RW et al. The burden of malaria in
pregnancy in malaria-endemic areas. American Journal of
Tropical Medicine and Hygiene, 2001, 64(1,2 S):28-35.
4. Molineaux L. Malaria and mortality: some
epidemiological considerations. Annals of Tropical Medicine
and Parasitology, 1997, 91(7):811-825.
5. Murphy SC, Breman JG. Gaps in the childhood
malaria burden in Africa: cerebral malaria, neurological
sequelae, anemia, respiratory distress, hypoglycemia, and
complications of pregnancy. American Journal of Tropical
Medicine and Hygiene, 2001, 64(1,2 S):57-67.
6. Mwageni E et al. Household wealth ranking
and risks of malaria mortality in rural Tanzania. In: Third
MIM Pan-African Conference on Malaria, Arusha, Tanzania, 17-22
November 2002. Bethesda, MD, Multilateral Initiative on
Malaria: abstract 12.
7. Report on the Zambia Roll Back Malaria
baseline study undertaken in 10 sentinel districts, July to
August 2001. Zambia, RBM National Secretariat, 2001.
8. Akazili J. Costs to households of seeking
malaria care in the Kassena-Nankana District of Northern
Ghana. In: Third MIM Pan-African Conference on Malaria, Arusha,
Tanzania, 17-22 November 2002. Bethesda, MD, Multilateral
Initiative on Malaria: abstract 473.
9. Breman JG. The ears of the hippopotamus:
manifestations, determinants, and estimates of the malaria
burden. American Journal of Tropical Medicine and Hygiene,
2001, 64(1,2 S):1-11.
10. Population and health in developing
countries. Vol. 1. Population, health and survival at INDEPTH
sites. Ottawa, International Development Research Centre,
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childhood malaria mortality in Africa: a new assessment of
progress toward targets based on verbal autopsy. [Lancet
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12. Trape J-F. The public health impact of
chloroquine resistance in Africa. American Journal of Tropical
Medicine and Hygiene, 2001, 64(1,2 S):12-17.
13. Grimwade K et al. HIV-infection in adults
increases rates of severe and fatal falciparum malaria in
regions of unstable transmission. In: XIVth International AIDS
conference 2002, Barcelona, Spain: abstract ThPeC7604.
14. Nwanyanwu OC et al. Malaria and human
immunodeficiency virus infection among male employees of a
sugar estate in Malawi. Transactions of the Royal Society of
Tropical Medicine and Hygiene, 1997, 91(5):567-569.
15. Mouchet J et al. Evolution of malaria in
Africa for the past 40 years: impact of climatic and human
factors. Journal of the American Mosquito Control Association,
16. Sharp B et al. Malaria control by residual
insecticide spraying in Chingola and Chililabombwe, Copperbelt
Province, Zambia. Tropical Medicine and International Health,
17. The World Health Report 2001. Mental
health: new understanding, new hope. Geneva, World Health
2. INSECTICIDE-TREATED NETS
the development of insecticide-treated nets (ITNs) as a new
technology in the mid-1980s, people in many countries were
already using nets, mainly to protect themselves against
biting insects and for cultural reasons (1-3). It was only
recently appreciated that a net treated with insecticide
offers much greater protection against malaria: not only does
the net act as a barrier to prevent mosquitoes biting, but
also the insecticide repels, inhibits, or kills any mosquitoes
attracted to feed. Thus ITNs provide protection both to
individuals sleeping under them and to other community
members. The effect is so significant that use of ITNs is
considered to be one of the most effective prevention measures
controlled trials in African settings of different
transmission intensities have shown that ITNs can reduce the
number of under-5 deaths by around one-fifth (5), saving about
6 lives for every 1000 children aged 1-59 months protected
each year (Figure 2.1). The incidence of clinical episodes of
Plasmodium falciparum infection is reduced by 50% on average.
When used by pregnant women, ITNs are also efficacious in
reducing maternal anaemia, placental infection, and low birth
may even be an underestimate of the efficacy of ITNs because
the impact of reduced mosquito burden extends to households
and communities without nets, which reduces the apparent
difference between study areas with nets and study areas
without nets. The protection afforded to non-users in the
vicinity is difficult to quantify, but it appears to extend
over several hundred metres. From observed reductions in
parasite prevalences, it has recently been estimated that, in
the long term, widespread use of ITNs - if regularly retreated
- will massively reduce malaria transmission (7), but this
effect will become fully apparent only after the usual 2-year
duration of a trial.
ITN trials achieved their impact with close to 100% of
households possessing nets and 50-75% of under-5s sleeping
under them, a level of use similar to the Abuja target of 60%.
Where lower coverage and use rates are achieved, the impact on
mortality will be less.
programmes have demonstrated the effectiveness of ITNs under
field conditions. In a large-scale social marketing programme
in two rural districts in the south of the United Republic of
Tanzania with high perennial malaria transmission, ITN
coverage of infants rose from less than 10% at baseline to
more than 50% 3 years later. ITN use was associated with a 27%
increase in survival of children aged 1 month to 4 years and a
63% reduction of anaemia in this same age group (evaluated by
case-control design) (8).
the Gambia, the National Impregnated Bednet Programme achieved
an 83% net treatment rate and reported 77% of under-5s and 78%
of women of childbearing age sleeping under ITNs (9). Overall
under-5 mortality fell by 25%, and case-control studies
suggested that there were 59% fewer episodes of uncomplicated
malaria in ITN users (10, 11).
Progress: ITN strategy plans
of the 40 malaria-endemic countries in Africa with country
strategy plans for rolling back malaria have developed
strategic plans which include increasing access to ITNs.
Twenty-five African countries have successfully applied for
funding in the second round of Global Fund applications.
Progress: taxes and tariffs
cost of ITNs is a barrier to their widespread use. As one
element in reducing prices, the Abuja Declaration committed
governments to "reduce or waive taxes and tariffs for
nets and materials, insecticides, antimalarial drugs and other
recommended goods and services that are needed for malaria
control strategies". Eighteen countries have now reduced
or eliminated taxes and tariffs (Figure 2.2). Time-limited
changes in tax or tariff regimes can be introduced through
informal agreements between health and finance ministries, but
more permanent arrangements normally require national
countries apply the "Harmonized Commodity Description and
Coding System" to classify products introduced by the
World Customs Office (12). Under this system, each product is
assigned a six-digit code for the purposes of levying tariffs
and collecting trade statistics. Nets are currently classified
as textiles and customs offices can be reluctant to give
exemption for the whole range of products covered by the code.
Some countries also subscribe to regional agreements on
tariffs and taxation rates, which can influence the adoption
of policy change. For example, the West African Economic and
Monetary Union requires all of its eight member states to
adhere to the Common External Tariff Resolution, which
stipulates fixed rates for import duty of 20% and for
value-added tax (VAT) of 18%. Clearly, changes in national
policy would be greatly facilitated by changes to
Progress: long-lasting insecticidal nets
response to low re-treatment rates of conventional
insecticide-treated nets, especially in Africa, WHO prompted
industry to develop long-lasting insecticidal nets (LLINs) -
ready-to-use, factory-pretreated nets that require no further
treatment during their expected lifespan of 4-5 years. This
technology obviates the need for re-treatment (unlike
conventional ITNs, LLINs resist washing) and reduces both
human exposure (at any given time, most of the insecticide is
hidden and not bioavailable) and the risk of environmental
the most recent fibre technologies, LLINs are regarded as a
major breakthrough in malaria prevention. One LLIN is already
commercially available and is recommended by WHO. At a current
price of around US$ 5 per net, LLINs are already more
cost-effective than conventionally treated nets. Efforts are
being made to scale up production capacity to meet demand,
which is already high. The RBM partnership is facilitating
technology transfer and stimulating local production of LLINs
in Africa (13).
In nine countries surveyed between 1997 and
2001, a median 13% of households possess one or more nets
(range 1.1-54%). A median 1.3% (range 0.2-4.9%) of households
surveyed in three countries own at least one ITN (14). The
proportion of under-5s sleeping under nets is also low - about
15% across 28 countries surveyed. Even fewer children (less
than 2%) sleep under ITNs. Only two countries, the Gambia and
Sao Tome and Principe, reported ITN use rates of more than 10%
current rates of coverage are generally low, the availability
and use of nets have increased appreciably over the past 10
years, particularly in countries where nets were not normally
used. In the United Republic of Tanzania, for example, nets
were rare in the 1980s, especially in rural areas, but
ownership has increased to 63% in towns and to 29% in rural
areas (14). Such trends are encouraging and highlight the
progress that is being made.
Challenges: increasing coverage
African households in malaria risk areas do not possess any
net, whether treated with insecticide or not. To achieve
adequate coverage most countries will require many more nets;
to cover all Africans at risk (16), an estimated total of 260
million nets would be needed.
ITN availability will require large-scale expansion of supply
and distribution. Barriers to increasing the supply and
distribution of nets and insecticides include taxes and
tariffs, regulatory issues, and inadequate distribution
systems. Barriers to increasing the demand for nets and
insecticides relate to the price, to their affordability for
households, and to promotion and marketing.
is also scope to increase the use of ITNs by providing
insecticide treatment for any untreated nets already in
houses. Based on the comparative coverage with untreated and
treated nets, this could double the percentage of households
insecticide re-treatment rates are another challenge.
Insecticide for net treatment is still an unfamiliar commodity
in Africa. Moreover, people's motivation for using nets is
often to reduce mosquito nuisance, not to repel or kill
malaria-transmitting mosquitoes. The increasing availability
of attractive branded formulations in Africa should stimulate
demand for insecticides, and the development of LLINs is
another potential solution to the problem of low re-treatment
Challenges: overcoming disparities in net coverage
A major barrier to net ownership is poverty.
The most common reason cited for not possessing a net is lack
of money: the price of a net represents a large proportion of
the income of a poor household.
possession and use have to increase considerably if the gap
between the number of under-5s who would benefit from a net
and those who currently sleep under one is to be reduced. The
challenge is to find the balance between covering the costs of
increasing ITN coverage and stimulating the growth of
commercial markets, while ensuring that the poorest and most
vulnerable are protected (23).
most malaria-endemic African countries the public sector does
not have the financial or logistic capacity to extend net use
to the scale required. Most countries spend only US$ 4 per
capita a year on health - the equivalent of the average cost
of an untreated net. The Abuja target for expanding ITN use in
Africa will therefore require synergy between public and
private sector activities.
providing an enabling environment for scaling-up actions,
governments need to focus on the following priorities:
- Creating demand for ITNs
through health information channels and mass media.
- Providing sustained
subsidies targeted to the most vulnerable groups,
preferably through a system that uses public channels
(e.g. at antenatal clinics) for delivery of subsidies but
commercial distribution channels for delivery of the
- Stimulating and
facilitating the development of commercial markets,
through tax and tariff reduction and by streamlining the
regulation of new insecticide products. Competition
between manufacturers and distributors must be promoted to
ensure that nets are available to the general population
at the lowest possible price.
- Monitoring insecticide
- Possibly, market priming
(i.e. the temporary procurement and distribution of ITNs,
aimed at strengthening commercial distribution channels)
in areas where the demand for nets is too low for
manufacturers to make an economical return.
To overcome the challenge of low re-treatment
rates, there should be a stronger role for subsidy of
insecticide distribution through publicly funded channels.
This is the system followed in the world's largest and
longest-sustained ITN programmes, namely those in China and
Viet Nam (23).
1. MacCormack CP, Snow RW. Gambian cultural
preferences in the use of insecticide-impregnated bed nets.
Journal of Tropical Medicine and Hygiene, 1986, 89(6):295-302.
2. Robert V, Carnevale P. Influence of
deltamethrin treatment of bed nets on malaria transmission in
the Kou valley, Burkina Faso. Bulletin of the World Health
Organization, 1991, 69(6):735-740.
3. Aikins MK, Pickering H, Greenwood BM.
Attitudes to malaria, traditional practices and bednets
(mosquito nets) as vector control measures: a comparative
study in five west African countries. Journal of Tropical
Medicine and Hygiene, 1994, 97(2):81-86.
4. The African summit on Roll Back Malaria.
Abuja, Nigeria, 25 April 2000. Geneva, World Health
Organization, 2000 (document WHO/CDS/RBM/2000.17).
5. Lengeler C. Insecticide-treated bednets and
curtains for preventing malaria (Cochrane Review). In: The
Cochrane Library, Issue 4. Oxford, Update Software, 2001.
6. Garner P, Gulmezoglu AM. Prevention versus
treatment for malaria in pregnant women. In: The Cochrane
Library, Issue 2. Oxford, Update Software, 2000.
7. Smith T et al. Effects of
insecticide-treated mosquito nets on malaria transmission. In:
Third European Congress on Tropical Medicine and International
Health, Lisbon, Portugal, 8-11 September 2002.
8. Armstrong Schellenberg JRM et al. Effect of
large-scale social marketing of insecticide-treated nets on
child survival in rural Tanzania. Lancet, 2001, 357:1241-1247.
9. Cham MK et al. Implementing a nationwide
insecticide-impregnated bednet programme in The Gambia. Health
Policy Plan, 1996, 11(3):292-298.
10. D'Alessandro U et al. The Gambian National
Impregnated Bed Net Programme: evaluation of effectiveness by
means of case-control studies. Transactions of the Royal
Society of Tropical Medicine and Hygiene, 1997, 91(6):638-642.
11. D'Alessandro U et al. Mortality and
morbidity from malaria in Gambian children after introduction
of an impregnated bednet programme. Lancet, 1995,
12. Harmonized Commodity Description And Coding
13. Guillet P et al. Long-lasting treated
mosquito nets: a breakthrough in malaria prevention. Bulletin
of the World Health Organization, 2001, 79(10):998.
14. Demographic and Health Surveys (DHS).
Calverton, MD, ORC Macro. http://www.measuredhs.com.
15. Progress Report Regional Procurement Centre,
Pretoria, South Africa. New York. United Nations Children's
16. MARA/ARMA collaboration (Mapping Malaria
Risk in Africa), July 2002. www.mara.org.za.
17. Mission Report on Mass Mosquito Net
Impregnation Campaign, Eritrea, 2002. Brazzaville, WHO
Regional Office for Africa (document WHO/AFRO/CDS/VBC/2002).
18. Chimumbwa J. A community-based programme in
Zambia. 1999. Luapula Community-based malaria prevention and
control programme. Presentation at Second International
Conference on Insecticide Treated Nets, Dar es Salaam, United
Republic of Tanzania, 11-14 October 1999.
19. Guyatt HL, Ochola SA, Snow RW. Too poor to
pay: charging for insecticide-treated bednets in highland
Kenya. Tropical Medicine and International Health, 2002,
20. Onwujekwe O et al. Hypothetical and actual
willingness to pay for insecticide-treated nets in five
Nigerian communities. Tropical Medicine and International
Health, 2001, 6(7):545-553.
21. Simon JL et al. How will the reduction of
tariffs and taxes on insecticide-treated bednets affect
household purchases? Bulletin of the World Health
Organization, 2002, 80(11):892-899.
22. Hanson K et al. Equity and ITNs in
Tanzania: evidence from a social marketing project. Third MIM
Pan-African Malaria Conference 2002, Arusha, Tanzania:
23. Global Partnership to Roll Back Malaria.
Scaling-up insecticide-treated netting programmes in Africa. A
strategic framework for coordinated national action. Geneva,
World Health Organization, 2002 (document WHO/CDS/RBM/2002.43.)
24. Phillips-Howard PA et al. The efficacy of
permethrin-treated bednets on child mortality and morbidity in
western Kenya. American Journal of Tropical Medicine and
Hygiene, 2003 (in press).
3. PROMPT AND EFFECTIVE TREATMENT
and effective treatment of malaria is a critical element of
malaria control (1). In Africa south of the Sahara, where most
malaria is due to Plasmodium falciparum and potentially fatal,
early and effective treatment could save many lives. It is
vital that sufferers, especially children aged under 5 years,
start treatment within 24 hours of the onset of symptoms, to
prevent progression - often rapid - to severe malaria and
strong health system would provide for reliable diagnosis as
the basis for optimal treatment. However, in most
malaria-endemic areas, access to curative and diagnostic
services is limited and drugs are purchased through the
private, informal sector (3, 4). Moreover, diagnosis is
complicated by the lack of a specific clinical presentation,
frequent occurrence of several diseases simultaneously, and -
in areas of intense transmission - asymptomatic malaria
infections. In high-transmission malaria-endemic areas, WHO
therefore recommends that, as part of the strategy of
Integrated Management of Childhood Illnesses (IMCI), all
under-5s with fever be presumptively treated with
antimalarials (5). Community-level interventions to strengthen
home management of children with fever are gaining importance
as part of efforts to improve access to prompt treatment,
particularly in isolated rural areas.
global consensus that access to prompt, effective treatment
should be a key element of the RBM strategy is based on the
widespread recognition that untreated falciparum malaria
contributes both directly and indirectly to the death of
non-immune individuals, sometimes within hours of the onset of
symptoms (2). Prompt, effective treatment of malaria and
appropriate management of clinical complications will be
studies in Madagascar (7) and the United Republic of Tanzania
(8) revealed significant reductions in mortality when research
teams provided prompt access to antimalarial treatment.
However, these studies took place in circumstances where the
obstacles to access that characterize most health systems in
endemic countries had been eliminated.
controlled trials of treatment of febrile illness with
reduction of mortality as the end-point are fraught with
methodological and ethical problems and have produced
conflicting results. In a widely quoted community-randomized
trial in an area of low, seasonal malaria transmission in
Ethiopia, under-5 mortality was reduced by 40% as a result of
teaching mothers to provide prompt chloroquine treatment for
fevers at home (9) (Figure 3.1). However, a general
improvement in child care may have contributed to this high
level of impact.