Malaria

Malaria is an urgent public health priority. The disease and the costs of its treatment trap families in a cycle of illness, suffering and poverty. Today, nearly half of the world’s population, most of whom live in sub-Saharan Africa, are at risk for developing malaria and facing its economic challenges.

Despite malaria’s heavy toll on health and economy, major inroads were made against the disease from 2000 to 2019 as a result of stepped-up funding and programming. Between 2000 and 2019, malaria mortality rates among all ages halved from about 30 to 13 per 100,000 population at risk. During this period, malaria deaths among children under 5 also declined by nearly half (47 per cent) from 781,000 in 2000 to 416,000 in 2019. However, the malaria mortality rate for all ages increased in 2020 to 15 per 100,000 population at risk, in part due to service disruptions related to the COVID-19 pandemic.

Success in the fight against malaria is fragile and closely tied to sustained investment. In recent years, there has been a plateau in the funding of the global malaria response. In 2020, the total of international and domestic funding for malaria control and elimination was $3.3 billion – less than half of what was needed. In order to achieve the goal of a malaria-free world, annual funding would need to more than double to reach the USD $6.8 billion target.

Impact of the COVID-19 pandemic and response

There is growing evidence that access to skilled and quality malaria services and care may have been negatively impacted by fears of infection and country responses to the COVID-19 pandemic, including lockdown measures, transportation disruptions, and diversion of resources away from essential health services. In 2020, for example, there were significant disruptions to bednet distribution campaigns due to COVID-19 mitigation efforts. 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, the production, procurement and delivery of ITNs, particularly long-lasting insecticide treated nets (LLINs), have accelerated, resulting in increased household ownership and use. Over 1 billion ITNs have been distributed in Africa since 2000, and annual distribution continues to increase. In 2020, manufacturers delivered about 229 million ITNs to malaria endemic countries, a decrease of 24 million ITNs compared with 2019.

Most countries in sub-Saharan Africa have made considerable progress in household ownership of ITNs/LLINs in recent years, with an average coverage of 66 per cent in 2021. However, ownership is uneven across countries, ranging from 31 per cent in Angola in 2016 to approximately 97 per cent in Guinea-Bissau in 2019. In addition, only 36 per cent of households had sufficient ITNs for all household members, which is drastically short of universal access to this preventive measure.

The percentage of children sleeping under ITNs in sub-Saharan Africa increased from less than 40 per cent in 2011 to over 50 per cent in 2021. But despite recent progress in sub-Saharan Africa, the 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. Large country and regional variations exist. For example, during 2015-2021 fewer than 25 per cent of children slept under an ITN in Angola and Zimbabwe, while over 90 per cent of children slept under an ITN in Guinea-Bisseau and Niger.

Most countries in sub-Saharan Africa increased ITN use among children under age 5 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 behaviour

Early diagnosis and treatment are essential for more favourable malaria outcomes. As fever is a key manifestation of malaria in children, particularly in malaria endemic regions, care-seeking for febrile children is crucial to reducing child morbidity and mortality. In sub-Saharan Africa in 2021, 61 per cent of children with a fever were taken for 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 be taken for care than those in rural areas. Disparities are also observed by wealth, with an 18 percentage point 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, the WHO recommended the universal use of diagnostic testing to confirm malaria infection before administering 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 about one in four (28 per cent) of children with a fever receiving medical advice or a rapid diagnostic test in 2021. There was a 10 percentage point gap in testing between the richest and the poorest children (33 per cent vs 23 per cent). Additionally, 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 developments in the official recommendations. WHO now recommends universal testing to confirm malaria. In response, many countries have expanded the use of diagnostic testing to focus treatment on those diagnosed with malaria. The current lower levels of antimalarial treatment in febrile children 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 had adopted ACT as the national policy for first-line treatment. The data continue to support, however, that other less effective antimalarial drugs are still commonly used. Treatment of malaria in children with ACT is low in sub-Saharan Africa with just over half (57 per cent) of children treated with anti-malarial drugs receiving the first-line treatment ACT in 2021. In West and Central Africa in particular, ACT treatment is alarmingly low – approximately half that of Eastern and Southern Africa (46 per cent vs 78 per cent). Available survey data indicate that ACT treatment does not differ greatly by residence or wealth within these regions.

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 the use of insecticide-treated bed nets (ITNs) as well as Intermittent preventive treatment during pregnancy (IPTp).

Regular use of ITNs by pregnant women is a vital intervention 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 remains too low.

Preventing malaria in pregnant women through IPTp with sulfadoxine-pyrimethamine 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, the 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 2015-2021, an average of 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 3 per cent at the lowest (Sao Tome and Principe) to 67 per cent at the highest (Zambia).

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.

Roll Back Malaria Partnership, Annual Report 2018. WHO, Geneva, May 2019.

Roll Back Malaria Investing in Malaria in Pregnancy in Sub-Saharan Africa: Saving Women’s and Children’s Lives.

UNICEF, The State of the World’s Children 2021, UNICEF, New York, 2019.

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

WHO, World Malaria Report 2021, WHO, Geneva, 2020.

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