Malaria

Malaria is an urgent public health priority. Malaria and the costs of treatment trap families in a cycle of illness, suffering and poverty. Today, 3.7 billion (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. As of 2018, direct costs of malaria are estimated to be $12 billion USD per year.

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 2017, the global total of international and domestic funding for malaria control and elimination was $3.1 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 $6.6 billion by 2020.

The impact of COVID-19

During the 2020 COVID-19 pandemic, there are additional risks to children’s health and wellbeing as the pandemic causes disruptions throughout the health system as well as the lives of families. In areas with health personnel become overstretched, key commodities become short in supply or where care-seeking behaviours are reduced transmission mitigation efforts (e.g. lockdowns, travel restrictions), this could result in more severe illness and higher mortality from malaria. Earlier this year, there were significant disruptions to bednet distribution campaigns due to COVID-19 mitigation efforts and there are concerns that these disruptions have also affected other malaria prevention and treatment programmes. Many of these disruptions have also coincided with malaria peak season, causing additional concern for the toll that the pandemic could have on malaria mortality and morbidity in children.

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, over 1 billion ITNs have been distributed in Africa. 34 per cent more ITNs were distributed from 2015-2017 than during the 2012-2014 cycle. Most countries in sub-Saharan Africa have made considerable progress in household ownership of ITNs/LLINs in the last decade, with an average coverage of 66 per cent. However, ownership is uneven across countries, ranging from less than 25 per cent in Namibia to approximately 90 per cent in Guinea-Bissau. Only 35 per cent of households had sufficient ITNs for all household members which is drastically short of the universal access of 100 per cent to this preventive measure.

Since 2002, the percentage of children sleeping under ITNs in sub-Saharan Africa increased from less than 5 per cent to over 50 per cent, with large country and regional variations. For instance, while the percentage in sub-Saharan Africa as a whole was 53 per cent in the 2013-2019 period, there are countries in the region with coverage below 25 per cent while others have coverage over 80 per cent. 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.

Most countries in sub-Saharan 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.

Care seeking

Early diagnosis and treatment are essential for more favourable malaria outcomes. As fever is a key manifestation of malaria in children, care-seeking for febrile children is crucial to reducing child morbidity and mortality. In sub-Saharan Africa, just under two in three (61 per cent) children with a fever sought advice or treatment from a health facility or provider. Data show disparities in care-seeking behaviour for febrile children by residence, with those living in urban areas more likely to seek care than those in rural areas. Disparities are also observed by wealth, with a 18 per cent difference in care-seeking behaviour between children in the richest (71 per cent) and the poorest (53 per cent) households.

Case management

Whilst fever is an indicator of malaria in children, it can also be a sign of other acute infections. In 2010, WHO recommended universal use of diagnostic testing to confirm malaria infection before applying any treatment. Malaria is diagnosed in febrile children by a rapid diagnostic test (RDT), which involves taking a blood sample from the finger or heel to test for malaria Plasmodium (P.) antigens. In sub-Saharan Africa, testing is low, with only one in four (28 per cent) children with a fever seeking advice or treatment receiving a RDT. There was a 12 per cent gap between those in the richest (34 per cent) and poorest (22 per cent) wealth quintiles, whilst a greater proportion of children in Eastern and Southern Africa (36 per cent) were tested than in West and Central Africa (21 per cent).

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 WHO’s recommendation advising universal testing to confirm malaria, with many countries 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 anti-malarials 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 P. falciparum is endemic, had adopted ACTs as national policy for first-line treatment. However, in surveys since 2013, fewer than half 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 half (59 per cent) of children treated with anti-malarial drugs receiving the first-line treatment ACT. ACT treatment in West and Central Africa is alarmingly low – approximately half that in Eastern and Southern Africa (46 per cent vs 81 per cent). The data indicate that ACT treatment does not differ greatly by residence or wealth within these regions.

As per the 11 nationally representative household surveys conducted in sub-Saharan Africa between 2013 and 2015, the median percentage 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 per cent. The median percentage of children under 5 receiving ACT was much smaller, at around 14 per cent. 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 per cent in 2010-2011 to 80 per cent 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 sub-Saharan 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. Methods to prevent malaria in pregnancy include:

• 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 2016, WHO issued a new recommendation that at least three doses of IPTp treatment should be given to pregnant women in malaria endemic regions, starting in their second trimester, with at least one month between each dose. Many countries are still in the process of scaling up this new recommendation.

Between 2014-2019, on average only 25 per cent of eligible women in sub-Saharan Africa received three or more doses of IPTp. The proportion of women receiving IPTp varies across the region, ranging from 8 per cent at the lowest (Chad) to 61 per cent at the highest (Ghana).

Download our 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, Annual Report 2018. WHO, Geneva, May 2019.

UNICEF, The State of the World’s Children 2017, UNICEF, New York, 2017.

WHO, Guidelines for the Treatment of Malaria: third edition, WHO, Geneva, 2015.

WHO, World Malaria Report 2018, WHO, Geneva, 2018.

WHO, Recommendations on antenatal care for a positive pregnancy experience, WHO, Geneva, 2016.