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World
Malaria Report 2005
UNICEF and the World Health Organization
May 03,
2005
http://rbm.who.int/wmr2005/index.html
To access the
Report Contents and downloadable PDF files for each section visit:
http://rbm.who.int/wmr2005/html/toc.htm
EXECUTIVE
SUMMARY
This
is the first comprehensive report by Roll Back Malaria (RBM) partners
on the status of malaria worldwide and on countries’ progress to
control the disease through effective treatment and prevention.
The report is based on the best information that was available to
the World Health Organization (WHO) and the United Nations Children’s
Fund (UNICEF) at the end of 2004 from routine reports, household
surveys and special studies.
Malaria remains
a major global problem, exacting an unacceptable toll on the health
and economic welfare of the world’s poorest communities. During
the past 4–5 years, however, substantial progress has been made
in initiating and scaling up programmes to provide prevention and
treatment to those who are most affected by this devastating disease.
During the 1980s
and 1990s, the burden of malaria increased in Africa. The reasons
for this increase were resistance to commonly used antimalarial
drugs, the deterioration of primary health services in many areas
and the emerging resistance of mosquitoes to insecticides used for
vector control. During the past decade, malaria also resurged or
increased in intensity in South-East Asia after interruption of
eradication efforts, and re-emerged in several Central Asian and
Transcaucasian countries.
Most countries
did not start implementing programmes to provide access to the tools
and strategies recommended by RBM until 2000. In many countries
in Africa where the burden of malaria is greatest, scaling up access
to treatment and prevention began even more recently. It is therefore
too soon to determine whether the global burden of malaria has increased
or decreased since 2000, given available data and scientific methods.
Not until several years after high coverage with malaria prevention
and treatment has been achieved will the worldwide impact on mortality
be measurable.
Some countries
have already made and demonstrated progress in reducing malaria.
The regional summaries that follow show progress in scaling up malaria
control throughout the world since 2000.
Regional
progress in access to treatment and prevention
AFRICA
In
2000, African countries committed themselves to providing by the
end of 2005 prompt and effective treatment and insecticide-treated
nets (ITNs) for 60% of the people at highest risk of malaria and
intermittent preventive treatment (IPT) for 60% of pregnant women.
Initially, implementation of these measures was severely limited
by a shortage of resources for procurement of commodities. Some
countries have reached or exceeded at least some of these targets
with recent increases in funding. Most remaining countries are now
poised to begin scaling up, although substantial challenges remain.
With respect
to prompt and effective treatment, surveys have shown that on average
half of African children with fever are treated with an antimalarial
drug, but most of these treatments involved chloroquine, against
which resistance of the P. falciparum parasite is very high.
Increasing availability of artemisinin-based combination therapy
(ACT), a new and highly effective treatment against falciparum malaria,
is expected to improve treatment outcomes within the next few years.
By the end of 2004, 23 African countries had changed their national
drug policy and adopted ACTs. In addition, 22 countries had adopted
and begun to implement the RBM-recommended strategy of home management
of malaria for children under 5 years of age—which involves education
and training of mothers and provision of pre-packaged high-quality
medicines—in order to provide more prompt treatment for children
in rural areas with poor access to facility-based care.
With respect
to progress on prevention, the number of ITNs distributed has increased
10-fold during the past 3 years in more than 14 African countries.
Subsidized or free-of-charge ITN distribution has proved successful
in increasing coverage of the most vulnerable populations. This
is often linked to antenatal care and/or child immunization services,
or national child immunization campaigns. Surveys conducted from
1999 to 2004, with the median survey year 2001, have shown that
the median proportion of children under 5 years of age using ITNs
was only 3% (ranging from 0.1% to 63% across 34 countries). There
is, however, indication of rapid improvement. Surveys conducted
in 2002–2004 showed remarkable increases in ITN coverage for children
under 5 years of age in countries such as Eritrea (63%) and Malawi
(36%). In selected areas of Senegal, household ownership of ITNs
increased from 11% in 2000 to 41% by 2004. Updated, wide-scale assessments
of ITN coverage are not yet available for most other countries.
Urban, relatively
wealthy households are far more likely to own ITNs than rural and
poorer households, in which people are at higher risk of malaria.
Some African countries have succeeded in breaking this pattern.
Programmes of highly subsidized ITN distribution through public
health services in Ghana and Nigeria, and a national campaign of
free ITN distribution alongside measles immunization for children
under 5 years of age in Togo, resulted in high coverage rates in
all population groups. In most African countries, many more households
have mosquito nets not treated with insecticide than ITNs. Scaling
up of insecticide re-treatment services will therefore also be an
important factor in increasing ITN coverage.
Efforts to prevent
the silent but significant burden of asymptomatic infections in
pregnant women residing in areas of stable malaria transmission
have been revitalized through partnerships between malaria and reproductive
health programmes. A total of 11 African countries, in addition
to scaling up delivery of ITNs to pregnant women, are now in the
process of implementing IPT for pregnant women.
ASIA
Malaria
remains a significant problem in the Eastern Mediterranean subregion,
especially in areas where, over the past 30 years, complex emergencies
and the associated destruction of health systems have aggravated
the disease situation. Since 1998–1999, regional expenditures on
malaria control have increased. The main control strategies are
access to prompt and effective treatment, indoor residual spraying
(IRS), epidemic preparedness and strengthening of surveillance systems.
These strategies have succeeded in halting or reversing the trend
of increasing case rates in many countries. In a high-risk area
of Yemen, for example, vector control and strengthened surveillance
with active community participation have succeeded in reducing the
number of malaria cases 10-fold since 2001.
Vivax malaria
resurged in Central Asia and Transcaucasia, and falciparum malaria
re-emerged in Tajikistan during the 1990s. Beginning in 2002, this
region stepped up vector control through ITNs and IRS. Some countries
also made considerable progress in surveillance methods and epidemic
preparedness. Kyrgyzstan, for example, reinforced surveillance,
used targeted IRS and improved case management in malaria-affected
areas in response to a 2002 epidemic. These efforts are keeping
malaria in check, although reported incidence remained around 10-fold
higher in 2003 than in 1990. Sustained commitment and adequate financial
support will be needed to prevent malaria from becoming a greater
problem.
South-East Asia
has the highest rate of drug resistance in the world, and multidrug
resistance has contributed to the re-emergence of malaria in many
areas, especially along international borders. Adults lacking immunity
who work in forested areas or as migratory labourers are at high
risk. Since 1998, all countries in the region have been routinely
monitoring drug resistance. Out of 9 countries in this region, 6
have adopted ACTs as a national policy for first-line treatment
of uncomplicated falciparum malaria. Challenges remain, however,
for improving access to ACTs in private clinics, pharmacies and
shops and in reducing the use of counterfeit and substandard drugs.
Improving capacity for laboratory diagnosis of malaria through microscopy
or rapid diagnostic tests is also a major focus of malaria control
efforts, particularly in remote areas where malaria risk is high.
All countries
in South-East Asia use IRS and/or larviciding for vector control
in selected areas most affected by malaria, and all include epidemic
preparedness and surveillance among national control strategies.
Use of IRS, chiefly with pyrethroid insecticides, and ITN distribution,
which started recently in most countries, have been associated with
reductions in reported case rates in selected areas. Indonesia and
Sri Lanka, for example, have had substantial successes. Sri Lanka,
which uses focused IRS in high-transmission areas, larviciding and
ITN distribution, ceased having epidemics after 1992 and reduced
malaria incidence to the lowest level observed since 1967. In a
high-risk area on central Java, Indonesia, improved diagnostic and
treatment services, including outreach to poor rural areas and ITN
distribution, halted and reversed a major malaria epidemic in 2001.
This project also provided the impetus for re-establishment of malaria
monitoring and surveillance systems.
In the Western
Pacific subregion, malaria control was revitalized in the mid-1990s
following a resurgence of the disease related to economic decline,
large-scale population movement and breakdown of disease control
and health-care services. Key strategies are vector control through
ITNs and IRS, epidemic preparedness and prompt and effective treatment.
Rates of reported cases fell gradually between 1992 and 2003. In
Viet Nam, the number of malaria deaths declined rapidly after introduction
and effective use of ACTs for first-line treatment. In a high-risk
area of Malaysia, ITN distribution and improved diagnosis and treatment
services offered by primary health-care volunteers reduced malaria
incidence 28-fold between 1995 and 2003.
THE AMERICAS
Malaria
transmission occurs in 9 countries of the region that share the
Amazon rainforest and in 8 countries in Central America and the
Caribbean. Population movements associated with gold mining and
forestry work have resulted in isolated epidemics. All affected
countries use IRS and/or larviciding in focal areas at risk. Nine
countries include ITNs in their national control strategies. Based
on demonstrated chloroquine resistance, 8 of the 9 Amazon countries
have recently changed national drug policies to use ACTs for the
treatment of falciparum malaria. Chloroquine has retained its efficacy
for treatment and prophylaxis against falciparum malaria in Central
America north of the Panama Canal, the Dominican Republic and Haiti,
and for treatment of vivax malaria throughout the region. A programme
of "focalized treatment" consisting of improved treatment
and IRS in focal areas successfully interrupted malaria transmission
throughout much of Mexico, while the rational utilization of insecticides
keeps costs low.
Meeting increased
demand and sustaining support for malaria control
The
estimated cost for supporting the minimal set of malaria interventions
required to effectively control malaria is around US$ 3.2 billion
per year for the 82 countries with the highest burden of malaria
(US$ 1.9 billion for Africa and US$ 1.2 billion elsewhere). Only
a fraction of that sum is available. Financial support and commitment
to malaria control have increased since the inception of RBM. However,
most of this increase has occurred during the past 2 years, and
there remains a huge resource gap, especially in high-burden countries.
At present,
according to available data, governments in malaria-affected countries
provide the main source of funds for national malaria control programmes.
In 2002–2003, governments provided 71% of total funds in Africa,
80% in Asia, and 96% in the Americas. Despite these investments
by national governments, the poorest countries tend to have the
highest burden of malaria, and national funding commitments are
unable to fill the gap between what is needed and what is available.
Thus, sustained and increased donor assistance will be required
for the foreseeable future.
The Global Fund
to Fight AIDS, Tuberculosis and Malaria (GFATM), which began disbursement
for malaria control in 2003, is an important international funding
source. The GFATM disbursed more than US$ 200 million in 2003–2004
to 28 countries in Africa, 15 countries in Asia and 4 countries
in the Americas. Approved commitments for malaria control for 2005–2006
total US$ 881 million.
ACTs, the most
effective available treatments against falciparum malaria, are 10
to 20 times more costly than chloroquine, the former mainstay of
therapy. The demand for ACTs has increased rapidly since the GFATM
began disbursing funds to countries. In 2004, this surge in demand
resulted in a shortage of artemether– lumefantrine (Coartem®),
the first ACT prequalified by WHO. Scaling up production of artemisinin—the
raw material needed to produce ACTs—is a high priority for RBM.
Improved forecasting of medication needs and financial commitment
by countries will be crucial if the pharmaceutical companies manufacturing
ACTs are to step up production. With respect to prevention, grants
from the GFATM that were approved in 2003–2004 are expected to provide
at least 108 million ITNs to countries.
Data collection
and reporting
Sources
of information relied on for global RBM monitoring include reports
from national malaria control programmes, household surveys, drug
efficacy monitoring at sentinel sites and health information systems.
National malaria
control programmes provide regular overviews of local malaria control
strategies and policies, financing of programme activities and service
delivery activities. Although reporting on programmatic indicators
is not fully standardized across regions and varying control strategies,
this information is useful for understanding changes in programme
performance.
Household (community-based)
surveys provide the most relevant data on coverage with ITNs and
access to malaria treatment. The national Multiple Indicator Cluster
Surveys supported by UNICEF and the Demographic and Health Surveys
conducted by Macro/Measure with support from the United States Agency
for International Development at five-year intervals in many countries
provide most data points. In 2004, RBM developed the Malaria Indicator
Survey package for use in monitoring trends to increase coverage
of malaria prevention and treatment. The Malaria Indicator Survey
can be used to conduct household surveys in the absence of other
surveys, or to fill gaps within the interval between subsequent
Demographic and Health Surveys or Multiple Indicator Cluster Surveys.
Surveys using this approach will be highly useful in preparing future
world malaria reports. The next round of Multiple Indicator Cluster
Surveys, to be conducted in 30 African malaria-endemic countries
in 2005–2006, is expected to provide additional reliable information
on increases in intervention coverage.
Drug efficacy
monitoring has in most regions greatly improved with the establishment
of surveillance systems, sentinel sites and standardized study protocols
within the past few years. These efforts are helping countries in
regular updating of national drug policies, and they should continue
to be expanded and supported.
For countries
in South-East Asia and the Americas, data from national health information
systems are generally believed to provide a useful indication of
trends in malaria cases and deaths. To improve the interpretation
of health information systems data, their completeness should be
assessed routinely in all countries using standardized methods.
In most African countries, only a minority of patients who are ill
with malaria are seen in medical facilities, thus health information
systems data do not paint a reliable, let alone complete, picture.
Here, major investments in health systems will be required before
the utility of health information systems for monitoring disease
trends can even be assessed, and population-level data are indispensable.
In addition to all-cause under-5 mortality, the prevalence of childhood
anaemia and malarial parasitaemia could be useful survey-based burden
indicators.
Conclusion
The
goal of the RBM Partnership is to halve the burden of malaria in
endemic countries by 2010. This report shows clear progress in scaling
up antimalarial interventions in many countries. In Africa, several
countries will reach at least some of the targets set by African
heads of state in Abuja in 2000. It is clear, however, that there
is much work to be done.
The strengthening
of countries’ health-care systems—and of monitoring and evaluation—is
paramount. At present it is too early to assess the impact of the
recent scale-up of malaria prevention and treatment, but there are
good reasons to believe a measurable reduction in morbidity and
mortality should start to become apparent in the second half of
the decade.
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