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It’s Past Time for a More Holistic Response to Malaria

On World Malaria Day 2016, Estrella Lasry of Médecins Sans Frontières calls for a more holistic approach if we are to make more than a dent in the malaria burden in areas most difficult to reach.

Since the early 2000s the world has seen considerable success in the fight against malaria, with a significant decrease in overall numbers of cases and deaths. But this success is uneven: there are still contexts where the toll of malaria is worsening and seasonal spikes in patient numbers are getting higher. Teams at projects run by Médecins Sans Frontières (MSF) saw particularly high peaks in 2012, 2014 and 2015—largely in the most difficult-to-reach areas of Democratic Republic of Congo (DRC), Central African Republic (CAR) and South Sudan, but also in countries like Uganda and Mali, which have stronger health systems.

A key question for the global health community has been: why?  Indeed, some of these countries are strongly affected by conflict, and consequently have seen large population movements—a factor which probably contributes to increases at the local level in certain locations. But in places like Yida, South Sudan, where the population has not grown, MSF outpatient facilities nevertheless treated nearly 3 times as many patients in 2015 compared with 2014 (7,532 in 2014 vs 19,338 in 2015[i])-, with a 4.2 -fold jump in cases during the peak period of September to December (4,052 in 2014 vs 17,055 in 2015),[i] even after consultation criteria were changed to include only those under 15 years old (healthcare for adults was provided by another organization).

These increases seem to be driven by multiple factors, both local and regional. One contributor is the El Niño effect, a well-known cause of increased temperatures, rainfall and humidity in Sub-Saharan Africa. These changes, in turn, could explain the rise in malaria cases through their effect on enhancing Anopheles mosquito development, survival, and capacity to transmit disease. Malaria spikes were documented in East Africa in 1997-98 and 2007, which were El Niño years, and strongly affected areas where the population had little immunity to the parasitic disease.

Another possible contributor to rising malaria burden in some regions is the growing insecticide resistance in Anopheles mosquitoes. Although data is scanty in many areas where MSF works, reduced efficacy has been reported for pyrethroids, the main insecticide used to impregnate bednets and for indoor residual spraying, in several African countries.

A third factor could be improved case reporting. However, case numbers are increasing even at MSF facilities in areas like Aweil, South Sudan, and Koutiala, Mali, where MSF has been working for years and there have been no significant changes in local access to healthcare or in data collection systems.

A family arrives at the middle of the night and prepares a bednet and mattress on the floor in the crowded hospital at Bentiu POC. Photo by Brendan Bannon. September 2015. Bentiu, South Sudan
A family arrives at the middle of the night and prepares a bednet and mattress on the floor in the crowded hospital at Bentiu POC. Photo by Brendan Bannon. September 2015. Bentiu, South Sudan

Whatever the causes may be, the response to these regional spikes has been largely reactive rather than proactive, which reduces effectiveness. Although both climate phenomena and resistance to insecticides were anticipated in advance and then documented when they materialized, little was done pre-emptively to prepare healthcare workers and facilities for the predictable increases in malaria they triggered.  South Sudan faces debilitating stockouts of antimalarial and other drugs, partly because health sector planning failed to take these malaria triggers into account and partly due to discontinuation of the Emergency Medicines Fund in June 2015.  In Aweil State Hospital, the only secondary healthcare facility for an estimated population of 1.2 million people, shortages of antimalarial drugs at primary healthcare facilities may have fueled the increasing numbers of severe malaria cases—MSF’s team at Aweil  treated  1162 cases of malaria in 2013,[i] 3529 in 2014 (also a malaria-intensive year, but MSF supported and stocked the outpatient facility), and 4588 in 2015. Yet in response to the increase in insecticide resistance, bednets impregnated with insecticides known to be less effective are still being ordered for distribution in several high-malaria countries.

Thankfully the response has been more effective on other fronts, particularly in rolling out more preventive interventions using antimalarials in these high-burden areas of West, Central and East Africa. Seasonal Malaria Chemoprevention, which uses non-artemisinin antimalarials for prevention in children under 5 in areas where malaria is seasonal, is now national policy in 13 countries of the Sahel; in 2016 over 15 million children will benefit from this intervention, which has been shown to reduce uncomplicated malaria by 80% and severe malaria by 70%. MSF has also implemented “one–shot” strategies in CAR and DRC, using artemisinin combination therapies for treatment and prevention of malaria—even, where possible, combining them with vaccination campaigns. However, these are temporary solutions that have not yet been shown to affect malaria epidemiology beyond the 4-5 weeks of protection provided by the drugs, and that may not be sustainable in the long run.

To significantly and sustainably decrease malaria burden in the most-affected countries, all relevant actors will need to adopt a more holistic approach—one that integrates interventions and research on health, climate, agriculture, (and eventually economics and housing) in tackling the main factors contributing to the disease and its transmission. This will require closer collaboration among different national ministries, UN agencies, research institutions, international organizations and NGOs to improve health, vector control activities, and in the future, education and improved housing. The current reactive “silo” approach will unfortunately only bring about temporary dents in malaria epidemiology, while requiring much more effort and investment.

Estrella Lasry is a New York-based Tropical Medicine Advisor for MSF.

Featured image: A family arrives at the  middle of the night and prepares a bednet and mattress on the floor in the crowded hospital at Bentiu POC. Photo by Brendan Bannon. September 2015. Bentiu, South Sudan

[i] MSF programmatic data

Discussion
  1. I still believe the solution to the malaria problem in Africa lies strongly on vector control via aggressive environmental sanitation- i.e elimination of breeding spaces for mosquitoes and this requires strong community mobilization and political commitment.
    Till date, billions of dollars has been channeled into projects to eliminate Malaria, and though some believe progress has been made – i believe better and faster progress can be made if there is a change of focus from just Chemo-prophylaxis and the use of insecticide treated nets to controlling environmental factors that encourage the dominance of mosquitoes in these areas.
    Just to paint the scenario- how i see the current malaria control efforts- : So , mosquitoes live in these tropical belt of Africa as it has a suitable habitat for its growth- and there are billions of these mosquitoes carrying the malaria parasite and looking to transmit it. . There are also billions of people living in these Endemic Countries . They take antimalarial drugs as prophylaxis and once its protection wanes, the mosquitoes bite and transmit the malaria parasite and then they treat themselves with more antimalarial , and get well and again, but only for a while as the mosquitoes strikes again and so the cycle continues . the bed nets are available for use at night but when one is not sleeping and wants to just relax outside , wearing long pants and shirts or draping your bed net around yourself i tell you can be cumber some. After a while Mosquitoes begin to develop resistance to the antimalarials and the search begins for new drugs- and so this cycle continues . The big Pharmas are also happy as more drugs mean more money.
    Nothing is done to the pools of stagnant water around living spaces or the debris that accumulate in drainages in market places and residential areas , where thousands of mosquitoes lift up their voices in hallowed salutation every evening. And the drums of water (storage tanks) which lie open, a back-up for unpredictable water supply in homes.
    Well, enough said !. the present situation of Zika virus in the Amazonia i believe teaches us a good lesson which i hope will be learned- the need to be proactive rather than reactive in our approach to disease control. The lessons learned in the past during the yellow fever outbreak, seem also to have been easily and quickly forgotten. The need remains to shift our focus and strengthen vector eradication efforts through environmental sanitation and community mobilisation. This is a more cost effective approach and could be supported with other methods of disease control e.g. chemotherapeutics, ITNs and so forth..

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