Malaria

Background

There were 250 million attacks of clinical malaria in 2006, leading to an estimated 881,000 deaths, mostly in Africa, mostly children, mostly poor. Malaria eradication campaigns involving extensive spraying of DDT successfully eliminated the disease from 37 previously endemic countries between 1940 and 1970, resulting in a significant worldwide reduction in mortality from the disease.  Yet in the 109 countries where malaria has remained endemic, mortality from the disease has been on the rise since 1980. This stems from growing insecticide and drug resistance and the deterioration of public health services, and is happening despite a clear undertanding of etiology, known and well established public and personal prevention methods, and affordable treatment options. In part this is because malaria, like HIV, varies from country to country and often is endemic - carried in the bloodstream of most people in a region but causing acute illnesses in only a handful.

Prevention of malaria is done primarily through the use of long-lasting insecticidal nets, indoor residual spraying, and intermittent treatment for pregnant women.  Diagnosis of malaria is conducted clinically and confirmed in the laboratory through blood microscopy, or rapid diagnostic tests where laboratory tests are unavailable.  In reality, in many countries all illnesses with high fevers are presumptively treated as malaria, leading to inappropriate therapy and overuse of medicines.
             
Since the 1970s, the standard treatment for Malaria has been the drug Chloroquine. However, strains of malaria have increasingly become resistant to Chloroquine and other major anti-malarial drugs.  In 2001 the World Health Organization recommended artemisinin-based combination therapies (ACT) as first-line treatment for malaria over Cloroquine, sulfadoxine-pyrimethamine (SP), quinine, artemisinin mono-therapy, or anti-pyretics. 

At around the same time large new funding sources - the Global Fund for Aids, TB, and Malaria; the US-based President's Malaria Initiative (PMI); the Gates Foundation, and others, begain adding large amounts of new money to malaria programs.

 

The Three Steps to Malaria Prevention and Treatment

Malaria is transmitted by the anopholese mosquito, biting mostly in the evening or early morning. At its most basic, malaria control and treatment programs do the following:

  • Indoor residual spraying (IRS) with insecticides, usually together with campains to remove standing water where larvae breed)
  • Distribution of Insecticide Treated Nets (ITNs - or LLINs if the insecticide is baked into the fabric and so 'long lasting')
  • Treatment of suspected malaria with either traditional therapies or new ACTs
  •  

    The Private Sector

    IRS. Indoor residual spraying involves coating indoor surfaces with a long lasting insecticide that kills mosquitoes that come into contact with the surface. IRS was one of the primary techniques during the early malaria eradication campaigns but high costs, environmental concerns, the need for extensive coverage in any given area, and negative publicity has rendered IRS a small niche in malaria eradication today.  Private sector spraying has occurred on the small scale, with no plans to increase private IRS programs.

    Nets. The private sector has played a large role in many countries in the fabrication, distribution, and sale of ITN and LLINs. However, free market costs have significantly limited access to nets in many low income countries. In response to this, nationwide social marketing programs have been developed as the cornerstone of malaria prevention programs in Kenya and many other countries. In Tanzania a national program provides socially marketed LLINs, and vouchers to reduce the cost for the poorest households

    Treatment. Over-The-Counter treatment for malaria has been the norm in most endemic countries for decades. The low cost of quinine, chloraquine, sulfadoxine-pyimethamine (SP), tetracyclin and other common therapies has made self-treatment via pharmacies and drug-seller supplied medicines the preferred source of care in all be the very poorest countries. The adoption of ACTs as national treatment norms poses a challenge thereofre as many people are unused to seeking care for malaria episodes in public facilities.

     

    Current Activities

    Free LLIN. WHO, the Global Fund, and the US President's Malaria Initiative have all called for free distribution of LLINs in recent years and have stepped up funding to national malaria control programs to make this possible. Skeptics worry that this will not reach many in need because of limited coverage of government programs, or that free nets will not be used, and that fully subsidized distribution will destroy supply chains and retail networks that have developed over many years, risking leaving millions with no source of nets at all if donor subsidies decline. In acknowledgement of this, many countries are supporting, or permitting, mixed markets with both free distribution and traditional and/or socially marketed net provision.

    AMFm. With British support, World Bank political backing, and Global Fund management, the newly created Affordable Medicines Facility for Malaria (AMFm) will accept round one applications on June 1, 2009 from 11 priority countries (see box). AMFm will primarily fund high subsidiziation of imported ACTs, which will then be sold on through traditional retail markets at a significantly reduced price to consumers. While the current cost of a full three day treatment with ACTs is around US $5.00; the target price to consumers for AMFm subsidized treatment is around US $0.10 for a full course.