GLOBAL OVERVIEW OF MALARIA
History of Malaria
Malaria is probably one of the oldest diseases known to mankind that has had profound impact on our history. Malaria was linked with poisonous vapours of swamps or stagnant water on the ground since time immemorial. This probable relationship was so firmly established that it gave the two most frequently used names to the disease mal’aria, which was later shortened to one word malaria. The term malaria (from the Italian mala “bad” and aria “air”) was used by the Italians as a misnomer describing cause of the intermittent fevers associated with exposure to marsh air or miasma. The causative agent was later isolated and known to be a parasite called plasmodium with different species, falciparum, vivax and malariae which is transmitted through a vector called anopheles mosquitoes. It is believed that most, if not all, of today’s populations of human malaria may have had their origin in West Africa (P. falciparum) and West and Central Africa (P. vivax) on the basis of the presence of homozygous alleles for hemoglobin C and RBC Duffy negativity that confer protection against P. falciparum and P. vivax respectively (Kakkilaya).
Global Spread of Malaria
From its origin in the West and Central Africa, malaria spread all across the globe to become the worst killer disease ever suffered by mankind. The parasites spread to other areas through the wandering of man, following the human migrations to the Mediterranean, Mesopotamia, the Indian peninsula and South-East Asia. Thus by 19th century, malaria reached its global limits with over one-half of the world’s population at significant risk. On the coasts of West Africa, mortality rates were remarkably high. From the mid-19th century onward, with the use of the Cinchona bark, mortality rates fell rapidly. However, early 20th century, repeated untreated infections of P. vivax and prolonged infections of P. malariae also contributed significantly to the mortality along with the lethal P. falciparum. Poor living conditions, poverty and famine probably contributed to the high mortality. During the past 100 years, nearly 150 million to 300 million people would have died from the effects of malaria, accounting for 2-5% of all deaths. In the early part of the century, malaria probably accounted for 10% of global deaths. By mid 20th century, the mortality started dropping, mainly as a result of the spontaneous decline in contact between human and vector populations as a result of improved living conditions as well as by the vector control measures. By the early 1950s, malaria almost disappeared from North America and from almost all of Europe. However, from the tropics where it is endemic, it can spread across continents through the vectors (mosquitoes) and the hosts (men) carried on the boats, trawlers, ships, jets and surface transport (Kakkilaya).
Epidemiology of Malaria in endemic Regions.
Prevalence of Malaria.
In 2008, cases of Malaria in sub-Saharan Africa (SSA) constituted 86% of the global total while south-east Asia accounted for 9% followed by Mediterranean Region with 3% (2008 WHO Report).
Causes of Malaria.
In 2008, Plasmodium falciparum was found to be responsible for over 75% of the cases in most SSA countries but was second to plasmodium vivax in most countries outside Africa (2008 WHO Report). Malaria vectors are Anopheles funestus and Anopheles gambiae mosquitoes, which bite late in the evening through early morning (Malaria Alert Centre, College of Medicine, Malawi).
MALARIA SITUATION IN MALAWI
Malawi is a land-locked country in southern Africa with a population of 13.1 million persons in 2008 (NSO). It is one of the poorest countries in the world with a gross domestic product (GDP) per capita of US $850 per year. Malawi faces many health problems. Communicable diseases mainly malaria, tuberculosis and HIV/AIDS are the main cause of morbidity and mortality in Malawi. The average life expectancy at birth was 49/51 years in males/females, respectively in 2006.
The Malawi Essential Health Package (EHP)
The Essential Health Package (EHP) is the health sector’s main pro-poor primary health care strategy which focuses the priority areas to achieve not only national goals set in the Malawi Poverty Reduction Strategy (MPRS), Malawi Growth and Development Strategy (MGDS) but also global goals like Millenium Development Goals (MDGs). It aims at addressing the major causes of morbidity and mortality among the general population focusing particularly on medical conditions and service gaps that disproportionately affect the rural poor. The Malawi EHP consists broadly of the following eleven intervention areas in order of priority from 2004 to 2010:
• Prevention and Treatment of vaccine preventable diseases,
• Malaria Prevention and Treatment,
• Reproductive Health Interventions
• Prevention, control and treatment of Tuberculosis and related complications,
• Prevention and treatment of Schistosomiasis and related complications,
• Management of Acute Respiratory Infections and related complications,
• Prevention, treatment and care for Acute Diarrhoeal Diseases (including cholera),
• Prevention and management of HIV/AIDS, Sexually Transmitted Infections and related complications including VCT and the provision of ARVT,
• Prevention and management of Malnutrition, Nutrition deficiencies
• Management of eye, ear and skin infections and related complications.
• Treatment of common injuries and their complications.
DISCUSSION OF THE MAIN CONTENT
Malaria is a major public health and economic problem in Malawi. All Malawians are at risk of contracting malaria. However, the poor are badly hit by the disease and as a result it makes them poorer. Adults lose an average of 25 working days per year, which results in significant lost family income. In addition, the cost of drugs to treat malaria can easily overwhelm family resources, especially those in the lowest income categories. In Malawi, it is estimated that low-income families spend more than one quarter (28%) of their yearly income to treat malaria (CDC). Children under five, pregnant women and those living with HIV/AIDS represent the most at-risk populations for malaria-related morbidity and mortality. It was estimated that there were approximately 680,000 pregnant women and 2.31 million children under five in Malawi in 2008 (Malawi’s National Malaria Control Programme). The peak transmission season for malaria in Malawi follows the rainy season which span from November to April.
The Ministry of Health (MOH) estimates that there are approximately eight million episodes of malaria per year, accounting for 40% of all outpatient visits. Over 85% of malaria infections in Malawi are due to Plasmodium falciparum. According to the 2003 Health Management Information System (HMIS) report, health facilities reported 250,000 – 350,000 malaria outpatient cases monthly throughout the country. Malaria is the number one cause of hospital admissions and the leading cause of death among children under five. Children under five suffer on average 9.7 malaria episodes per year, while adults suffer 6.1 such episodes (Ettling et al., 1994). Malaria accounts for 39% of causes of in-patient admissions, while severe anaemia, most of which is attributable to malaria, accounts for an additional 11%. The malaria inpatient death rate is 2/1000 in under five as compared to 0.3/1000 in those over five in 2006 (NHS). This is quite concerning especially as the overall mortality among children under the age of five years has dropped from 189, 133,122, 111/1000 live births from 2000, 2004, 2006, 2008 respectively (DHS). There is growing evidence that the rapid scale-up of malaria prevention and control measures during the last two to three years is producing a significant reduction in the frequency of malaria infections and associated anemia.
MALAWI’S MALARIA CONTROL PROGRAM, POLICY, AND INTERVENTIONS
Malawi’s National Malaria Control Programme (NMCP)
The National Malaria Control Program (NMCP) functions under the Directorate of Preventive Health Services in the MOH. It was established in 1989 and has the legal frame work which was enacted as a component of the Malawi National Health Policy (MNHP). The main vision or goal of NMCP in Malawi is to reduce the malaria-related morbidity and mortality from 2004 figures by 50% by 2010 and 75% by 2015. The functions of the department are not only for setting policies, establishing strategies, coordinating, monitoring and evaluating activities, providing technical guidance but also for mobilizing resources for the program.
There are five zonal offices in the country which are responsible for overseeing malaria activities in their respective 5-7 districts. The District Health Management Team (DHMT) headed by the District Health Officer (DHO) is responsible for designating a District Malaria Control Coordinator to assist them for planning, costing, executing/implementing, monitoring, supervising, evaluating, coordinating and reporting the district malaria activities.
The Malawi National Malaria Technical Committee (MNMTC)
It is a commanding power of both national and expatriate malaria experts which was established to support the NMCP with technical expertise of information on prevention, control, research activities and advice on areas of coordination, collaboration, and research needs before transforming them into national malaria policies, prevention and control strategies.
Malaria Prevention and Control Interventions:
A. Health Promotion (Information, Education and Communication or IEC)
This is the first primary prevention of malaria in Malawi against both the vector and the parasite. The Malawi NMCP has made a substantial stride in providing public health awareness to the communities regardless of all forms of physical, terrain, cultural, religious and financial barriers. Every person from the age of childhood to adulthood in Malawi equates fever to Malaria. This is attributed to the intersectoral, community involvement and massive health promotion campaigns against malaria causes, transmission, prevention, symptoms and signs and prompt health seeking behavoiur at all levels using any informal and formal population gatherings. The media forms for dissemination included wall painting (houses of chiefs and other influencial leaders etc), print, electronic, formal and informal health education.
B. Distribution and Usage of Long Lasting Insecticide Treated nets (LLITNs)
This is another primary prevention of malaria in Malawi which targets the vector. Sleeping under ITNs is a proven method of preventing malaria. Following research trials in Africa in 1996, the World Health Organization (WHO) reported that “the lives of some 500,000 African children might be saved each year from malaria if the nets, treated with biodegradable pyrethroid insecticide, were widely and properly used.” More recently, the WHO Roll Back Malaria (RBM) initiative called for a 30-fold increase in ITN use. PSI/Malawi responded with an ITN social marketing initiative centered in Blantyre District, Malawi. In January 2000, this project expanded to become the first national ITN program in Africa. Malawi adopted a new ITN policy in 2006 which included free distribution of ITNs for newborn children born in health facilities, children attending their first EPI visit (if an ITN was not received at birth), and pregnant women at first visit to an antenatal clinic. The new policy supported time-limited, national, free distribution campaigns every 2-3 years targeting the most vulnerable populations in rural Malawi. Additionally, the program with support from donors and NGOs developed other innovations targeting the rural communities in collaboration with District Health Offices. Long-lasting ITNs were the preferred ITN for scaling-up coverage nationally. With additional support from the vibrant Joint Health SWAP, Malawi managed to distribute close to 2 million, 700,000 and 2 million ITNs nationwide in 2006, 2007 and 2008, respectively. Studies had shown insignificant abuse of the nets for other purposes like for fishing and covering nursery beds (Malaria Alert, College of Medicine) such that even after three years, people were able to show their ITNs. However, on the intended utilization of the ITNs, the study results were disappointing (although no known prevalence) because it was feared that a good proportion of people were not sleeping under the nets due some reasons. What reasons? Further studies are needed.
C. Intermittent Presumptive Treatment (IPTp) for Malaria in Pregnancy.
This is also a primary preventive intervention against malaria parasite through chemoprophlaxis which is aimed at sustaining effective and potent anti-malarial blood level circulation during pregnancy. Physiologically, pregnancy is a risk factor in endemic areas. In collaboration with Reproductive Health Directorate in the MOH, the NMCP has intergrated the intervention with a comprehensive antenatal care (ANC) package. Malawi’s policy on IPTp recommends the provision of at least two doses of SP directly observed by a skilled health worker, two months apart to pregnant women during the second and third trimester as a way of preventing malaria infection. The programme is proving to be effective although the second dose coverage remains relatively low, 47% to 52% in 2006 to 2008, respectively due to late registration of ANC visits (second or third semester); while the first dose remains outstanding, at over 98% (NHS). This has partly contributed to the reduction of infant mortality rate from 134 to 72 deaths per 1000 live births from 1990 to 2006, respectively (NHS).
D. Indoor Residual Spray (IRS)
This is the fourth recommended primary prevention of malaria against the vector. It is the application of a long acting insecticide on the walls of all houses and other shelters in a given area in order to kill the adult vector mosquitoes that land and rest on the surfaces. This is the latest malaria intervention to be adopted by the Malawi NMCP (National Entomologist, MOH 2009). In Malawi, insecticide ICON-CS (Lambda-Cyhalothrin capsule suspension) which is a pyrethrin is the recommended choice which is among the insecticide recommended by WHO. It is an effective intervention, however, it is not only expensive but also commands a good level of expertise. DDT is probably the cheapest insecticide among those recommended by WHO, however, many stalkeholders in Malawi denounced against it because of its side effects to both humans and the environment. With financial and technical support from the PMI, pilot study of IRS amongst 25,000 households in Nkhotakota District in collaboration with the Dwangwa Sugar Estates in 2007 was conducted to ascertain the feasibility of operational, logistical, and human resource requirements to scale-up IRS in rural Malawi. Through the routine monitoring and evaluating the programme, it has proven to be an effective complementary intervention to ITNs. In 2008, the programme was rolled out only to other 8 worst risk districts due to financial constraints.
E. Malaria Vaccine Third Efficacy Clinical Field Trial
The largest world’s malaria vaccine trial which is in its last stage is being conducted in seven African countries namely Burkina Faso, Gabon, Ghana, Kenya, Malawi, Mozambique and Tanzania involving 16,000 children (UNC Project-Malawi). There are high hopes for the better.
F. Malaria Case Management in Malawi
When all the above mentioned primary preventive interventions are not used properly or have failed, then the index victims are beaten by mosquitoes (with the malaria parasites) and eventually are infected with the malaria parasites. The NMCP policy emphasizes prompt diagnosis and treatment at all levels.
Prompt diagnosis means accessing the malaria parasite test, either through rapid diagnostic tests or through gold standard, namely blood smears at the laboratory level within 24 hours of onset of the symptoms.
Prompt treatment means accessing the recommended anti-malarial drug within 24 hours of onset of malaria symptoms. The 2004 WHO SSA Malaria Report elaborated that in 2003 the official WHO first line anti-malarial policy for Africa recommended usage of either chloroquine (CQ) or sulphadoxine pyrimethamine (SP). Malawi NMCP was implementing the intervention using CQ which was later in 1993 changed to SP because of resistance of malaria parasite to the former. Quinine remained the second line drug of choice against malaria in case management in Malawi. While in 2008, WHO SSA Malaria Report elaborated that in 2007, the recommended official WHO first line anti-malarial drug for Africa was artemisin-based combination therapy (ACTs) which is too expensive for most of countries within the region. However, the decision came about due to increased resistance of malaria parasite to SP over the years. Therefore, WHO elicited substantial funding and logistical support from among others, the Global Fund to fight AIDS, TB and Malaria; the World Bank, Roll Back Malaria, the President’s USA Malaria Initiative (PMI), Medicines for Malaria Venture and the Bill & Melinda Gates Foundation. In 2006, the Malawi’s MOH selected artemether-lumefantrine (AL) as the first-line drug and selected amodiaquine-artesunate (AQ/AS) as the second-line ACTs, reserving quinine for the treatment of severe malaria cases and for the management of malaria in pregnancy. The introduction of these drugs is in line with the WHO recommendation to use artemisinin combination therapies (ACTs) in order to improve malaria treatment and prolong therapeutic life of anti-malarial drugs. The new drug policy started to be implemented in November, 2007 with financial and technical support from PMI to run only from 2007 to 2009. Thereafter, it is anticipated that the Malawi Government should starting shouldering the whole transactions through the Joint Health SWAP Programme. Is Malawi SWAP ready to take over? It remains an open question.
G. Tertiary Malaria Prevention in Malawi.
Severe Malaria manifests clinically as normal malaria with atleast a complication. Malaria complications ranges from anaemia, cardiac failure, renal failure, liver failure, convulsions (cerebral malaria) as well as its sequelae leading to seizures, tropical spleen syndrome and death especially in under five children to miscarriage (abortion), underweight neonates and death in pregnant mothers and neonates. Therefore, the NMCP in collaboration with Directorate of Clinical Services advocates prompt effective treatment of simple malaria to prevent worsening into complications. Therefore, this is regarded as tertiary prevention of malaria in Malawi. The intervention seems to have positive impact in the health system in the country because it is partly contributing to the notable reduction not only in infant mortality rate from 134 to 72 deaths per 1000 live births from 1990 to 2006, respectively (NHS) but also maternal mortality ratio from 1120 to 807 deaths per 100,000 live births from 2004 to 2008, respectively.
Malawi’s Partners in Malaria Control and Prevention
• Malawi Ministry of Health
• College of Medicine, Malaria Alert Centre, Blantyre
• CHAM and Private Health Institutions
• All other Government Sectors
• All NGOs involved in Malaria Issues in Malawi.
• Centers for Disease Control and Prevention
• Michigan State University
• United Nations Children’s Fund (UNICEF)
• University of North Carolina
• Wellcome Trust/Liverpool School of Tropical Medicine
• World Health Organization
• A variety of other international and nongovernmental organizations, including Population Services International (PSI)
Current Sources of Support for Malaria Prevention and Control
• The Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)
• U.K.’s Department for International Development (DFID)
• Japan International Cooperation Agency (JICA) United Nations
• U.S. Agency for International Development (USAID) World Bank
(Compiled by Malaria Branch, Centers for Disease Control and Prevention, February, 2004)
In conclusion, malaria remains a health burden in endemic areas in SSA, including Malawi; South-East Asia and Mediterranean Regions.
In Malawi, Malaria is the major health problem. However, there is a strong collective effort at global, regional and national levels to mitigate the malaria burden. There are four main preventive and control intervention mainstreamed by NMCP, namely health promotion, intergrated vector control management (LLITNs and IRS), IPTp and Malaria Case Management. Malawi has a robust organizational frame work and institutional structures in place under the stewardship of NMCP. Therefore, there is a need to implement the national malaria control activities comprehensively and reviewing them regularly in order to win the battle against malaria. Yes! Malawi can manage to lessen the health burden caused by malaria further to insignificant levels, thanks to mainstreaming guidance by NMCP.