Malaria by Global Health Council

Malaria

A Global Health Council Position Paper

March 2011

Malaria continues to threaten millions of lives around the world, especially those of poor women and children. However, significant progress has been made over the last decade thanks to increased coordination, political will, and the resources to bring new tools to more of those who need them. Thousands of children have been saved and malaria cases have started to drop in some areas. Scale up of control programs has confirmed that available interventions cost little when compared with the health benefits they return. More research is needed to develop new prevention methods, stave off drug and insecticide resistance, and optimize the delivery and use of current tools. Malaria prevention, treatment, and research efforts must be accelerated to eliminate the burden of this disease across Africa, Asia, and the Americas.

The Global View Half of the world’s population, living in more than 100 countries, is at risk of contracting malaria. Approximately 225 million people became ill with malaria in 2009.1 Five different parasites cause malaria. Two, Plasmodium falciparum and Plasmodium vivax, cause the majority of illness and are present in Africa, Asia, and the Americas. The World Health Organization (WHO) estimates that 781,000 people died from malaria in 2009.1 Some experts believe the true number of annual deaths may be much higher, as malaria deaths are often attributed to other causes.2, 3 Children are more likely to develop severe malaria because they have not yet developed any immunity to the disease—85 percent of malaria deaths are among children under the age of five.1 Ninety-one percent of deaths due to malaria occur in Africa.1 Pregnancy decreases immunity to malaria and increases susceptibility to severe anemia and death.4 Maternal malaria also increases the risk of miscarriage, stillbirth, premature birth, and low birth weight.5 Low birth weight due to malaria causes approximately 100,000 infant deaths each year in Africa.5 Malaria affects people living in poverty disproportionately, monopolizing scarce resources and contributing to a cycle of poverty. Families suffer both direct health care costs and the indirect costs of lost wages, either because workers themselves become ill or because they take time from work to care for sick family members. Lost productivity is estimated to reduce gross domestic product growth by 1.3 percent per year in malaria-endemic countries in Africa.6 Malaria consumes up to one-quarter of household income

in some high-burden countries.7 Malaria control has received increasing international attention and support in the last decade. Millennium Development Goal (MDG) 6 commits countries to halt and begin to reverse malaria incidence by 2015.8 The Roll Back Malaria Partnership’s Global Malaria Action Plan (GMAP) sets the following goals for 2015: reduction of global malaria cases by 75 percent (from 2000 levels); reduction of preventable malaria deaths to near zero; and elimination of malaria transmission in ten countries.9 Preventing and treating malaria will also have a positive impact on MDGs 1, 4 and 5 by reducing poverty and child mortality and by improving maternal health. Since 2002, funding for malaria control programs has increased each year, including considerable investments through the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Malaria Initiative (PMI), and the private sector.10 Increased, equitable and effective financing is needed to maintain current gains and advance elimination efforts.11 Funding for malaria increased 18-fold between 2003 and 2010, from US$99 million to US$1.8 billion.1, 12 Total funding would need to increase to US$5-6 billion per year, or about three times current levels, to meet the 2015 goals and sustain progress towards malaria elimination and eradication.9 As part of the U.S. Global Health Initiative, the PMI invested US$1.3 billion between 2006 and 2010, providing 57 million antimalarial treatments and 27 million insecticide-treated nets (ITNs) to 15 malaria-endemic countries in Africa.13

The Need for Prevention ITNs and indoor residual spraying (IRS) prevent bites from malaria-transmitting mosquitoes. Long-lasting ITNs (also known as LLINs) are effective for several years and are now the most widely-used type of ITN. Consistent ITN use can prevent about half of malaria cases in children.14, 15

Though most countries’ policies recommend ACTs for malaria treatment, they are often unavailable due to supply shortages and distribution problems. ACTs are 4-22 times more expensive than monotherapies, making them prohibitively expensive for poor familes.1

Distribution and use of ITNs has increased significantly since 2000. In sub-Saharan Africa, the percentage of households owning at least one ITN increased from 3 percent in 2000 to 42 percent in 2010.1 This increase, however, still fell short of the goal of 80 percent coverage set out in the GMAP.9

Overall coverage of ACTs is still low in many high-burden countries. For example, in nine countries with high levels of P. falciparum malaria, only 16 percent of malaria cases were treated with ACTs in 2008.23

ITNs and IRS prevented the deaths of at least 736,700 African children between 2000 and 2010; there was an 18 percent reduction in child deaths due to malaria during this time period.16 In areas with high malaria transmission, intermittent preventive treatment (IPT) is recommended for pregnant women and infants to prevent severe complications of malaria.17, 18 Recent evidence suggests that IPT can help prevent malaria in children as well.19, 20

The Need for Treatment One in two malaria deaths could be prevented by ready access to rapid diagnosis and prompt treatment with appropriate medications.21, 22 Rapid diagnostic tests (RDTs) allow health care workers to diagnose malaria quickly and without laboratory facilities, a major advantage in resource-poor settings. However, distribution of RDTs has been uneven and they remain unavailable in many low-income countries due to cost (US$0.781.17 per test).9 Artemisinin-based combination therapies (ACTs) are combinations of multiple antimalarial medications. They are more effective than single drug therapies (monotherapies) and they reduce the risk that drug resistance will develop.

The Need for Research In recent years, there has been renewed interest in malaria eradication—the complete global elimination of malaria.24-28 This goal cannot be achieved with existing prevention and treatment methods and resources; research is needed to develop new tools for vector control, diagnosis, and treatment.29 New malaria medications are urgently needed. Resistance to artemisinin, a key ingredient in ACTs, has already been found in Asia.30 If this resistance spreads, it could jeopardize the last effective treatment for most types of malaria. The Medicines for Malaria Venture and other product development partnerships (PDPs) are working to develop new drugs to effectively treat malaria in ACT-resistant areas, but it will be several years before these medications are available. There are currently no vaccines that prevent malaria, however several are in development. One candidate, the result of a Malaria Vaccine Initiative PDP, was recently shown to be 46 percent effective at preventing malaria in young children.31 If testing continues to go well, this vaccine could be introduced in 2015.32 Efficient program implementation is needed to achieve the full benefit of malaria interventions. Operational research should be conducted to develop methods for identifying delivery bottlenecks and integrating malaria programs with other health programs.33

Key Interventions for Malaria

P. falciparum malaria transmission,* 200734

Distribute long-lasting insecticide-treated nets (ITNs); Educate communities about ITN use and mosquito prevention;

* Red—high transmission; pink—low transmission; light gray—no transmission; dark gray—unknown.

Number of child malaria deaths prevented by ITNs and IRS in Africa, 2001–201016

Implement indoor residual spraying (IRS) programs; Promote intermittent preventive therapy (IPT) for pregnant women and infants; Encourage mothers to seek care for children with fevers; Expand access to rapid diagnostic tests (RDTs) and artemisinin-based combination therapies (ACTs); Ensure health care facilities are adequately and consistently stocked;

Cost-effectiveness of preventive malaria interventions9, 35-37 Percent reduction in Cost per DALY** malaria cases averted

Intervention

Cost*

Intermittent preventive treatment in pregnancy

$0.30

$13-24

Intermittent preventive treatment for infants

$0.35-0.50

$3-30

Long-lasting insecticide-treated nets

$6.41

$5-17

Indoor residual spraying

$7.50

$9-24

* Estimates include implementation costs and are per treatment, net, or round of spraying. All estimates are in 2008 US$, except for intermittent preventive treatment for infants, which is in 2007 US$. ** Disability-adjusted life year.

Enact and enforce policies to eliminate monotherapies, counterfeit, and substandard drugs; Optimize impact through operational and implementation research; Strengthen capacity of laboratories and surveillance systems; Integrate malaria programs with maternal, newborn, child and reproductive health programs; Support research to develop new vaccines, treatments, and preventive methods.

Policy Principles Unified Strategy

Targeted Interventions

Country-led Plans

Increased Investment

Effective Partnership

Global health stakeholders should implement the agreed-upon goals for malaria in a coordinated approach to achieve universal access to prevention, treatment and care.

Approaches should reflect the overall disease burden in each country, while incorporating strategies to address the underlying causes of morbidity and mortality, the population’s needs, and the capacity of national and local health systems.

The malaria strategy should be led by national governments in partnership with other stakeholders and should be responsive to existing structures and capacity.

Higher investments are needed by donors and national governments to expand prevention and treatment services; funding must reflect country priorities; and donor investments should focus on countries most in need.

International stakeholders need to establish effective partnerships and greater harmonization of programmatic and funding efforts to promote holistic and integrated malaria strategies and programs.

Recommendations Support country-led development and implementation of strategic national plans based on evidence, including epidemiologic assessments that target interventions to areas with the highest malaria burden. Increase commitments from donors and endemic country governments to ensure sufficient resources to meet the Millennium Development Goals and the Global Malaria Action Plan targets. Scale up and sustain coverage of cost-effective prevention interventions, such as insecticide-treated nets (ITNs), indoor residual spraying (IRS) and intermittent preventive treatment among all at-risk populations, particularly pregnant women, infants, and children. Increase access to and utilization of rapid diagnostic tests (RDTs) to identify malaria cases and provide appropriate treatment. Provide incentives to reduce the cost of RDTs and educate health professionals about their proper use. Impede the spread of drug and insecticide resistance by maintaining strong surveillance and adhering to international reporting requirements. Ensure appropriate use of antimalarial medications and invest in the development of new, safe and effective public health insecticides. Enact and enforce policies to eliminate monotherapies and

substandard and counterfeit drugs from the market while providing arteminisin-based combination therapy for all uncomplicated cases of P. falciparum malaria. Develop new and improved preventive, diagnostic and treatment technologies and support implementation and operations research to improve program effectiveness. Strengthen health systems by improving diagnostic and surveillance capabilities, increasing efficiency of supply chains, and training health professionals. Integrate services where appropriate and feasible—particularly utilizing existing HIV/AIDS, maternal and child health, and other infectious disease platforms. Reduce the cost of and increase access to antimalarial medications, ITNs, insecticides, and RDTs by removing unnecessary taxes and tariffs. Focus on human resources for health at the district and community level—training health care workers and program managers to efficiently and effectively implement prevention and treatment programs. Continue investments in behavior change communication to ensure effective use of preventive and treatment commodities and improve prevention and treatment practices.

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