New strategy needed as global fight against Malaria stalls

Progress against malaria has stalled, sparking fears that the disease is roaring back in regions where cases had been falling for the past decade.

As Kenya joins the world in marking World Malaria Day the World Health Organisation (WHO) has warned that the global response towards malaria has stalled due to levelling off of funding and an increase in new cases. The situation is threatening to reverse efforts to control the disease.

Figures from the World Malaria Report 2017 show that progress in pushing down infections and deaths from malaria has stalled and even reversed in some countries.

An estimated 216 million cases of malaria worldwide were reported in 2016, a majority of which were in sub-Saharan Africa.

Of those infected, a staggering 445,000 died with 16,000 of the deaths occurring in Kenya. This translates to 1,219 lives lost every day, or nearly one a minute. For children it is a particularly devastating disease, with about 70 per cent of those deaths involving children under five.

Kenya is ranked among 15 countries in sub-Saharan Africa that accounted for 80 per cent of all malaria cases in the world in 2016.

In the past 16 years, the Kenyan government has made great strides in preventing and controlling malaria by issuing insecticide-treated bed nets, spraying people’s homes with insecticides and ensuring that there is widespread diagnostic testing.

These efforts have resulted in a significant drop in malaria transmission rates, resulting in a reduction of cases from 11 per cent in 2010 to eight per cent in 2016, according to the Ministry of Health.

However, the decrease in cases has not been uniform. For instance, whereas cases in malaria-endemic regions like Mombasa have reduced, other parts of the country have registered an upsurge, making the country lose momentum.

In Western Kenya, we reduced the cases from 80 per cent to 40 per cent. However, for the last six years, the rate of decline has stagnated, meaning that the mechanisms we are using, the bed nets, antimalarials and insecticides are no longer as strong as they used to be,” says Dr Simon Kariuki, a chief research officer at Kemri’s Centre for Global Health Research in Kisumu.

Scientists are worried about stagnation in counties with high cases of malaria that once enjoyed rapid declines. “In Western Kenya, we reduced the cases from 80 per cent to 40 per cent. However, for the last six years, the rate of decline has stagnated, meaning that the mechanisms we are using, the bed nets, antimalarials and insecticides are no longer as strong as they used to be,” says Dr Simon Kariuki, a chief research officer at Kemri’s Centre for Global Health Research in Kisumu.

Dr Kariuki also says there is an upsurge in cases in places that previously did not have malaria, due to changes in climate, coupled with a population which lacks natural immunity against the disease.

With the global response to malaria at a crossroads, global leaders and philanthropists announced new commitments towards ending the mosquito-borne disease.

The renewed action and boosted funding to fight malaria are expected to prevent about 350 million cases of the disease in the next five years and save 650,000 lives across commonwealth countries.

To achieve this, philanthropists, business leaders and heads of state pledged Sh410billion ($4.1billion) to drive research and innovation and improve access to malaria prevention and treatment.

Malaria endemic

The pledge announced last week at the Malaria Summit London 2018 will specially be focused on children and pregnant women, who are most at risk of being infected with malaria.

Apart from malaria endemic regions of Western Kenya and Coast, counties in the west of the country along the Rift Valley are still plagued by serious seasonal cases of the deadly disease. Seasonal outbreaks of malaria in these counties are most common in the wet season, which runs from March to June and then again from October to December.

As a result, in February this year, for example, the arid counties of Baringo, West Pokot and Marsabit saw an outbreak where hundreds of people were hospitalised. Most of the patients were children under the age of five – a group that’s globally considered a high risk for severe malaria.

This follows a similar case that occurred in October last year when at least five counties and a refugee camp were hard hit by malaria outbreaks that killed about 30 people including four children.

According to the Ministry of Health, about 733 cases were reported in Marsabit, Lamu, Turkana, Baringo, lower West Pokot and Kakuma refugee camp, where 438 people tested positive for the disease.

Some of the issues identified by scientists as setbacks include improper use of antimalarial medicines as well as transmission of latent malaria through blood transfusion.

A large proportion of malaria patients in endemic countries in Africa are likely to receive doses of malaria medicine that are too low to offer effective treatment, according to new research.

Researchers found that an estimated 21.3 million people (24 per cent of all confirmed malaria cases) were at risk of being prescribed inadequate doses of artemisinin-based combination therapy (commonly known as ACTs), the frontline treatment against Plasmodium falciparum malaria.

Malnourished children under five years, overweight and obese adults, pregnant women, patients with uncomplicated severe falciparum malaria (and patients using poor quality medicines) were at risk of prescribed inadequate doses of antimalarial medicines. The conclusion was based upon a review of data from 40 endemic countries where a total of 89.6 million cases of malaria were reported in 2015.

“Antimalarial drugs remain a key tool for the control and elimination of malaria. These findings are worrying given that sub-optimal dosing among vulnerable populations not only leads to poorer treatment outcomes for patients, but can also fuel the emergence and spread of antimalarial drug resistance,” said Dr Kasia Stepniewska, lead researcher on the study.

Dr Stepniewska, who is also the head of statistics at the Worldwide Antimalarial Resistance Network (WWARN), added: “There is an urgent need to tailor therapeutic approaches for populations at risk in order to protect the efficacy of drugs and prevent the development of drug resistance.”

More resistant

If malaria treatments are not strong enough to eliminate the malaria parasites in a patient, the remaining parasites that withstood the low doses could evolve to become more resistant to future treatment.

Other studies in Kenya, Nigeria and Uganda, however, have found that there is over-prescription of malaria drugs, which can potentially fuel drug resistance, the researchers said.
“While artemisinin resistance has not yet been confirmed in Africa, we can do a lot more to improve how we use antimalarials and so reduce the risk of artemisinin and partner drug resistance becoming established here,” said Karen Barnes, professor of clinical pharmacology at the University of Cape Town

Improper use of medicines, however, is not a problem that is unique to malaria, as the WHO estimates that more than half of all medicines are inappropriately prescribed, dispensed or sold.

The problem is especially acute in developing countries, where it is compounded by health system weaknesses such as heavy patient loads, lack of enforced regulations, pressure of promotional activities, and lack of supervision, monitoring and evaluation.
But under-dosing is just one of the areas that may be causing a setback in the fight and elimination of malaria.

According to findings presented at the same conference, malaria-infected blood could also be driving up cases of the mosquito-borne disease. The team of scientists also found that about one in four (25 per cent) blood bank supplies in sub-Saharan Africa contain malaria parasites.

If the world is to eliminate malaria, the scientists said, all sources of disease transmission, including the region’s blood banks, need to be addressed, especially in sub-Saharan Africa, which carries 90 per cent of all malaria cases.

There was a big push to eradicate the disease in the fifties and sixties, but when the global focus shifted, malaria returned with a vengeance, gaining a stranglehold on Africa.

A second push in the past decade initially made strong headway, reducing cases by about 20 per cent in just five years.
However, once again progress has slowed, with five million more cases in 2016 than the previous year.
Now a major new fightback is being planned. According to the WHO, with the right focus, funding and international cooperation it should be possible to eradicate the disease by 2030.