By Elisabeth Wilhelm
MACEPA Advocacy and Communications Global Health Corps Fellow1
Malaria evolved along with humans over 60,000 years ago and has plagued and killed people ever since. For just as long, humans have been looking for ways to prevent infection and eliminate the disease.
Tools and knowledge have evolved to combat malaria in the past several hundred years: quinine’s protective properties against malaria were discovered in the 17th century and in 1880 mosquitoes were discovered as the vectors for malaria.2 Insecticides were first used for malaria control in the early 20th century and then impregnated into bednets for mass distribution in the 1990s. Major advances in global health research and development have propelled efforts to eliminating malaria, including more sensitive diagnostics, new effective treatments as old ones began to fail, and perhaps most importantly, developing robust, evidence-based programmatic strategies to systematically fight the disease in countries.
Today, thanks in part to these innovations we are closer than ever to a major global health milestone: the elimination of malaria from entire sub-Saharan African countries, where over 90 percent of all malaria deaths occur.
Which malaria control strategies that have been proven to work in other settings can we use to eliminate malaria in sub-Saharan Africa? Which approaches are cost-effective and keep kids under five years of age, the most vulnerable population, out of clinic beds and bouncing on their mother’s knees?
- Insecticide-treated bednets for everyone who needs one: With universal coverage the goal, 136 million insecticide-treated bednets were distributed in sub-Saharan Africa in 2013, nearly twice the number compared to 2012, and more nets are moving in the pipeline in 2014. Sleeping under a treated bednet short-circuits the malaria transmission cycle from mosquito to human and has contributed to a reduction in all-cause mortality in children under five by 20 percent.
- Improved malaria case management: In malaria-endemic areas, people are learning to recognize early malaria symptoms so that they seek treatment before the malaria becomes life-threatening and more have access to drugs and rapid diagnostic tests (RDTs) in their communities. Community health workers are being trained to diagnose and treat malaria, meaning people don’t need to travel long distances to clinics for these services. In 2012, 205 million RDTs were sold, 15 million patients were tested for malaria in their communities, and 331 million doses of ACT were administered.
- Preventing malaria in pregnancy: Low birth weight is the most common side effect for a pregnant woman who has malaria in sub-Saharan Africa. Treating pregnant women for malaria using intermittent preventive treatment in pregnancy (IPTp) protects both the mother’s and baby’s health. Since 2009, 94,000 newborns were saved with a combination of anti-malaria interventions within three years. This approach has been adopted as national health policy in 36 countries in sub-Saharan Africa.
- Increased community surveillance: To combat the parasite most effectively, a health system needs to know where to find it in the local population. Community surveillance activities proactively test people for malaria and treat them before they become very sick, which costs more to manage. Malaria cases detected by community surveillance activities climbed from 10 percent to 14 percent globally in 2012. Strengthened national health reporting systems and increased uptake in mobile health technology will encourage that percentage to grow. This data will aid in developing targeted malaria control programs because we know that different interventions are more suitable depending on climate, geography, and cultural norms.
With significant gains achieved, some countries are now piloting strategies to eliminate the disease altogether. Since every country has a different malaria epidemic profile requiring a tailored response, developing approaches that are adaptable and adoptable across different transmission settings will be key.
No single solution will eliminate malaria, but with a combination of intensive community surveillance, implementing indoor residual spraying and long-lasting insecticide-treated net distribution, and population-wide testing and treating activities, supported by an all-hands-on-deck community engagement approach, we can stop transmission from community to community.
Mass drug administration (MDA), for example, is one promising strategy that has worked well for trachoma and river blindness and can be applied to malaria. In malaria MDA, giving everyone anti-malaria medication in a population reduces the reservoir of parasites in both people who are sick with this disease and those who feel fine but are asymptomatic carriers. Therefore, the chances that a mosquito biting someone will successfully transmit the parasite to someone else are reduced. If a small regional trial using all of these strategies is successful, this approach can be scaled up nationally and then across sub-Saharan Africa.
Treatments and preventative measures for malaria have been in development for over a hundred years, but the current generation of malaria control professionals are applying the best and newest tools for the job of eliminating malaria from entire countries. That is a malaria-free future the whole world should fully invest in.
1Global Health Corps places pairs of health equity leaders under 30 into health organizations across five sub-Saharan African countries for a year to work toward better health outcomes for the most vulnerable. Elisabeth Wilhelm is a Global Health Corps Fellow working at the MACEPA program at PATH in Lusaka, Zambia, on community engagement and communications issues around malaria elimination campaigns.
2CDC.gov, “The History of Malaria, an Ancient Disease.”