Is Kenya winning the battle against malaria?

A mother and her child sleep under a mosquito treated net. The United Nations Millenium Development Goals (MDG) report for 2013 indicates that, between 2000 and 2010, deaths from malaria fell globally by 25 per cent, and that about 1.1 million potentially fatal infections were averted. PHOTO | FILE

What you need to know:

  • Unlike the other sites, Kilifi District Hospital is a malaria research centre and all children admitted in the paediatric ward have a malaria test since the start of the programme in 1989. A diagnosis of malaria is, therefore, not in doubt.
  • The bad news is that paediatric admissions for malaria went up by 55 per cent in Bungoma and by35 per cent in Siaya.
  • The scaling up of interventions has had a helping hand in pushing it down, aided by drug change, improvement in socio-economic status and improved health care seeking behaviour.

Today is World Malaria Day and, as we review global progress in combating the disease, evidence gathered over the last few years is giving us reason to hope.

The victories may be somewhat small, but they are still a step in the right direction. The United Nations Millenium Development Goals (MDG) report for 2013 indicates that, between 2000 and 2010, deaths from malaria fell globally by 25 per cent, and that about 1.1 million potentially fatal infections were averted.

This achievement has been made through concerted efforts that started in 1998, when the World Health Organisation set up the Roll Back Malaria Initiative to rally the world to provide funds in the fight against the killer disease. As a result of the initiative, global support for malaria control grew from US$100 million (Sh8.7 billion) in 1998 to US$5.6 billion (Sh487 billion) by the end of 2009.

The effects of that funding were quite encouraging: by 2005, scientists were already reporting declining malaria infections in various parts of Africa, including South Africa, Eritrea, Zanzibar, Ethiopia, Sao Tome and Principe, The Gambia and Rwanda.

Observers began spreading the gospel that malaria was undergoing a transition period in Africa, and such excitement rubbed on donors like the Bill and Melinda Gates Foundation. Soon, such phrases as “malaria eradication” found their way into the global narrative.

Dr Abdisalan Noor, a Kenyan scientist, took note of the trend and started poring over the details; and his findings, published in The Lancet journal in February this year, caused a lot of excitement in the malaria world.

Dr Noor collected data from 26,000 surveys in Africa — upto 2010 — and compared it with that from 2000. The findings were startling: malaria transmission, Dr Noor discovered, had dropped in 40 of the 44 countries. And, in seven countries, there were signs that the disease would be no more in a few years if the trend continued. However, the sobering part of Dr Noor’s work is the warning that 57 per cent of the African population still lives in areas with moderate malaria transmission.

In Kenya, Kilifi District Hospital has observed a massive decline in malaria admissions among children under five years of age, and Prof Kevin Marsh, chair of the WHO Malaria Policy Advisory Committee and also Director of the Kenya Medical Research Institute-Wellcome Trust Research Programme (KEMRI-WTRP), is an excited man.

“When we started working here in 1989,” remembers Prof Marsh, thousands of children were being admitted every year with severe malaria and hundreds of deaths occurred. Now, only a few hundred are admitted every year, with very few resultant deaths. The reduction from the peak when we arrived to now is about 80 to 90 per cent.”

As Kilifi continues to observe this decline, scientists are seeking to find out whether the same picture is being replicated across the country.

Research scientist Dr Emelda Okiro of KEMRI-WTRP, for instance, looked at malaria admissions in children under five years of age (paediatric malaria admissions) in various government hospitals in Kenya and published the findings in the Malaria Journal in 2010. Dr Okiro compared data from 2003 to 2006 and 2006 to 2009 — this separation of the study period was informed by the fact that 2006 was the year when a massive scale-up of malaria intervention programmes started in Kenya.

In 2006, the Ministry of Health got funding from the Global Fund to launch a large-scale distribution of free mosquito nets to children under five years. At the same time, a highly effective drug, Artemether-Lumefathrine (AL) was launched for malaria treatment, and Dr Okiro sought to find out whether these changes had made any impact on paediatric malaria admissions.

She pored over data from eight government facilities across various malaria zones in the country that included Bungoma, Kisumu, Siaya, Kericho, Kisii, Kilifi, Malindi and Msambweni.

The results were a mixed bag.

Starting with the good news, there was a marked decline in paediatric malaria in six hospitals. Kilifi recorded an impressive decline in malaria admissions of 69 per cent, followed by Malindi, with 61 per cent.

“The truth is likely to be that malaria has fallen by a massive amount all down the coast of Kenya,” says Prof Marsh of KEMRI-WTRP regarding the findings. “But detection of that fall was slower in areas with no research unit. So Malindi and Msambweni might have reported falls as high as those in Kilifi had good laboratory facilities been available there throughout the study period.”

Unlike the other sites, Kilifi District Hospital is a malaria research centre and all children admitted in the paediatric ward have a malaria test since the start of the programme in 1989. A diagnosis of malaria is, therefore, not in doubt. In other hospitals, malaria was diagnosed mainly from clinical symptoms and often any child with fever and no other obvious diagnosis was treated as a malaria case. It is likely, therefore, that some of the children treated for malaria, according to hospital notes, were suffering from something else.

But the glowing results from the Coast as well as great tidings in the highlands (Kericho and Kisii) as well as Kisumu are dampened by the gloomy picture in Western parts of Kenya. The bad news is that paediatric admissions for malaria went up by 55 per cent in Bungoma and by35 per cent in Siaya.

Dr Okiro proposed that, because Siaya and Bungoma had very high malaria transmission rates at the start of the study, it would be harder to bring down their rates of admissions as quickly as in the other areas. Think of it as emptying a small puddle of water compared to emptying a swimming pool; it is not impossible, but takes a lot more effort to make an observable difference and is a harder job to finish.

Dr Okiro attempted to explain her findings by looking at insecticide-treated mosquito net (ITN) coverage in the various regions. In 2003, net coverage in all the regions was less than one per cent. But by 2007, when free mass distribution campaigns were widespread, the average coverage was 40 per cent.

However, this was not uniform across the regions. Declines in malaria were highest in areas were post-scaled up net coverage was highest (Kisumu, Kisii and Malindi), while net coverage was lowest in Siaya and Bungoma, where malaria increased.

However, it is not all doom and gloom. This peak in paediatric malaria admissions after the introduction of intervention programmes in areas with extremely high transmission has been expected among malaria scientists.

“What is happening in Western Kenya may be part of the process of decline, that peak before the fall, and paediatric admission rates may soon start to fall,” explains Prof Marsh. “However, for more impressive falls in such admissions to be observed, something more needs to be done.

Residents of Western Kenya may have good net coverage, but they need universal coverage to ensure that absolutely everyone sleeps under a net. Second, every malaria patient needs to get rapid access to a full course of Artemether-Lumefathrine.

These two things are an integral part of the national malarial control programmes, and if the policy was implemented in full, malaria rates would begin to drop in Western Kenya.”

The impact of poor access to good and effective anti-malarials was reported by Mary Hamel and colleagues from KEMRI-CDC Kisumu, and published in the American Journal of Tropical Medicine and Hygiene in 2011. Ms Hamel reported an increase in paediatric malaria deaths for the period between 2008 and 2009 in Asembo and Gem in Nyanza province.

These deaths were attributed to the stock-out of Artemether-Lumefathrine for a seven-month period which included the peak malaria season. It is likely, also, that this stock-out may have affected the hospitals in Siaya and Bungoma and led to increased severe malaria in Western Kenya, which in turn toned down the impact of scaled-up interventions.

By compiling data over several years, Dr Okiro was able to make an interesting finding: that paediatric malaria admissions in Kilifi, Malindi, Kisumu and Msambweni started to occur long before the scaling up of intervention programmes.

Prof Marsh admits that the decline is a complex mix of factors and cannot be explained by just one variable. “Malaria has been declining for the last 15 to 20 years, especially along the eastern coast of Africa.

The scaling up of interventions has had a helping hand in pushing it down, aided by drug change, improvement in socio-economic status and improved health care seeking behaviour.

Climate change may also be implicated as the region is drying up, reducing mosquito breeding sites.”

The only problem with this complex picture is that if there is a change in any of the underlying issues, then it is likely that there will be an upsurge of malaria which will be difficult to comprehend. If an El-Nino repeat occurs, or drug shortages hit us, for example, it is not impossible to imagine an upsurge of malaria which may give the impression that the scaling up of interventions is not working, which is not the case.

As chair of the committee that sets global policy for malaria control, however, Prof Marsh is optimistic about Kenya:

“Kenya is doing well. The malaria control programme in Kenya is organised, but it could do better. The country needs to focus on making the most of the existing interventions. Wherever there is malaria in Kenya, there ought to be universal coverage with insecticide-treated nets and universal coverage of safe and effective drugs. Kenya has plenty of room for improvement in pushing these two areas forward.”