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Africa
Malaria Day, Five Years Later, How Far Have We Come?
Joas B Rugemalila, Charles L Wanga, Wen L
Kilama
Multilateral
Initiative on Malaria (MIM) Secretariat
Email:
info@mimalaria.org Website:
www.mimalaria.org
Introduction
Malaria is a preventable disease that
afflicts hundreds of millions of people causing among them
untoward socio-economic suffering including a vicious circle of
abject poverty, brain damage, other irreversible disabilities,
and over one million deaths per year. Notwithstanding this
leading disease burden, malaria has yet to get the status it
deserves on the political and other relevant agenda of endemic
communities and development partners. The historic Abuja
Declaration on Malaria promulgated by the Summit on Malaria in
Abuja, Nigeria on 25th April 2000, like many other preceding
ones, remains mostly on the drawing board as demonstrated by
available statistics. (1)
As we commemorate the Africa Malaria Day on
25 April 2006 we should note among other observations that there
is yet much to be done in sub-Sahara Africa where malaria exalts
the greatest toll. No more than 60% of those suffering from
malaria have prompt access to and are able to use correct,
affordable and appropriate treatment within 24 hours of onset of
symptoms(2). Only 60% of those at risk of malaria, particularly
pregnant women and children under-five years of age benefit from
the most effective combination of personal and community
protective measures such as insecticide treated nets and other
interventions. Of all pregnant women only 60% have access to
chemoprophylaxis by presumptive intermittent treatment. Yet
Africa Malaria Day has been commemorated since 2001. This
article explores the current situation and what is being done to
address the malaria problem.
Disease Burden
Malaria, a Public Health Crisis
In Africa alone, the economic burden is about
US$ 12 billion annually. Malaria is estimated to slow economic
growth in African countries by about 1.3% per year. The disease
contributes not only to lost life and productivity but also
hampers children's education and social development through both
absenteeism and neurological disabilities associated with severe
malaria. Malaria erodes growth, for example, when adults,
debilitated by the disease, cannot work, and lose earnings.
Furthermore, the education system becomes disrupted when
children are either too sick to attend school, or their teachers
are absent because of malaria-related illnesses (3, 4).
The malaria toll is staggering. Every 40
seconds a child dies of malaria, resulting in a daily loss of
more than 2,000 young lives worldwide. It is the leading cause
of mortality and morbidity worldwide; there are 300 to 500
million clinical cases every year and between one and three
million deaths, mostly children, attributable to this disease.
Ninety per cent of those who die are in Africa, where malaria
accounts for about one in five of all childhood deaths.
It can leave victims cognitively
disabled. The malaria parasite also interacts with other
afflictions, such as HIV and under-nutrition, in ways that are
still not well understood. These estimates render malaria
the pre-eminent tropical parasitic disease and one of the top
three killers among communicable diseases.
Disease History
Man and malaria seem to have evolved
together. It is believed that most, if not all, of today's
populations of human malaria may have had their origin in West
Africa
Hippocrates was the first to describe the
manifestations of the disease, and relate them to the time of
year and to where the patients lived - before this, the
supernatural was blamed. The association with stagnant waters
(breeding grounds for Anopheles) led the Romans to begin
drainage programs, the first intervention against malaria. The
word mal/aria meaning bad air has its origins there. The first
recorded treatment dates back to 1600, when the bitter bark of
the cinchona tree in Peru used by the native Peruvian Indians to
treat fevers came to the attention of Europe. Through the
Jesuits
Similarly 2000 years ago the Chinese
developed a fever medicine from the wormwood Artemisia annua
from which artimisinins which when combined with other medicines
are the leading malaria treatment today. They constitute part of
Artimisinin Combined Therapies (ACTs). This plant is becoming a
new cash crop in some parts of East Africa.
Not until 1889 was the protozoal cause of
malaria elicited by Laveran working in Algeria, and only in 1897
was the Anopheles mosquito demonstrated to be the vector
for the disease. At this point the major features of the
epidemiology of malaria seemed clear, and control measures
started to be implemented. In east Africa for example, during
the early 1900s European colonizers took quinine regularly as
preventive treatment. At the same time they started controlling
mosquito breeding in towns where they mainly lived and in mines
and farms which supplied goods to European industries. (5)
The Second World War was a boon to the malaria effort; it
brought the warring powers into the tropics, where malaria was
rife. It was therefore essential to discover, develop and deploy
new malaria control tools in order to protect the forces exposed
to malaria and other tropical diseases. So it was part of the
war effort that led to the introduction of such new malaria
control
products as DDT and related insecticidal chemicals. Chloroquine
and its relatives, which later constituted the mainstay of
malaria prevention and control were also part of the war effort.
Even SP was developed in order to contain chloroquine resistant
malaria during the Vietnam War.
After the WWII
both DDT and chloroquine entered civilian use. These chemicals
were so efficacious and effective that they led to their use in
community wide malaria control. By the 1950s there was so much
confidence in the prowess of these tools, that an all out war to
eradicate malaria from the entire world was declared; it would
mainly rely on DDT and chloroquine.
What went
wrong?
Despite initial
success, especially in Europe and North America where the
disease was completely eradicated, success elsewhere was mixed.
In Latin America and many parts of Asia, there were successes,
mainly at control. In Africa the picture was mixed. In a few
areas, for example the southern fringes of malaria transmission,
the high altitude areas, islands far from the African continent,
there were good signs of mastering malaria. In many parts of
Africa though particularly in the Savannas success was very
limited. As a result, and taking into account the historical
tumultuous changes of the early 1960s, malaria eradication in
Africa was totally abandoned. Countries in Asia and Latin
America persisted in their efforts, and the differences in the
malaria picture in these continents versus Africa is very
obvious
Recently
African countries that have reverted to DDT use have seen
spectacular successes in their malaria control efforts. These
include South Africa, Mozambique, Zambia, Madagascar and
Swaziland who within two years of starting DDT programs, slashed
their malaria rates by 75 percent or more. With fewer people
getting sick, they could access ACT drugs to nearly all victims,
and cut rates even further. Surely other African countries
should learn from these shining examples, instead of sitting on
the fence appeasing environmentalists, who care less of human
life.
Why the
failure?
Malaria, a
neglected disease
Malaria is a
classic neglected disease, characterized by a high disease
burden in the developing world, a low disease burden in
high-income nations, and a low level of funding in relation to
the disease burden. As with other neglected diseases, the
perceived lack of a lucrative consumer market for antimalarial
products is used to explain the relatively low rate of research
and development (R&D) investment by the private sector and why
government support has historically formed the cornerstone of
malaria R&D funding (6).
As stated
earlier many of the best antimalarial medicines benefited from
war effort research investments. Not infrequently such
investments ceased during years of peace. The development
insecticidal chemicals enjoyed great investments not only during
the war years, but also during peace. Indeed much of this
investment was initially meant for agricultural purposes. Quite
often chemicals successful in agriculture use were later tried
for public health use, and if successful they stood a chance for
introduction in community wide disease control.
The
insecticides used on bed nets today, which are called
pyrethroids, illustrate the point well. They were introduced in
agriculture during the 1970s. In the following decade (1980s)
trials on bed nets started. By the mid 1980s scientists working
in Gambia and Tanzania published papers demonstrating their
efficacy in mosquito control; by the early 1990s there were
already publications confirming their protection of human
beings. Unfortunately it is only now, close to three decades
after their introduction in agriculture, that we are witnessing
attempts at their mass scale up for real public health impact.
Furthermore the
impact of these insecticides cannot be expected to last for
ever; indeed there is already good scientific evidence
predicting their future failure. When they fail, if the global
insecticidal arsenal has not changed, there will be no fall back
position. As the chemical industry is least interested in
developing protective products for the poor, and governments,
particularly of malaria endemic countries which need the
alternative are more or less incapacitated, their might be real
grave danger when pyrethroid resistance increases to the point
of affecting control programmes. The only hope on the horizon is
the Bill and Melinda Gates Foundation who recently provided a
grant to the Liverpool School of Tropical Medicine to develop a
completely new class of safe insecticides, which would provide
a fall back position .
Malaria
resurgence
Continental
sub-Saharan Africa was never a part of the global malaria
eradication program. The severity of the disease, the density
and efficiency of An. Gambiae mosquito vectors, the
problem of eradicating the disease over such a large land mass
with recurrent reinvasions, high costs, and subsequent
maintenance must have all contributed to the lack of will to
undertake an eradication program. Also, the eradication program
period coincided with the colonial and immediate postcolonial
period, during which little or no indigenous capacity was
available to initiate and sustain malaria eradication. After a
period of laissez faire regarding malaria control, these
countries have had to face the re-emergence of the disease.
In recent
years, reported malaria cases have been rising especially in
Sub-Saharan Africa. In part, this rise may be due to the
improved coverage of Health Information Systems (HIS) and
misdiagnosis due to a general rise in fevers associated with
other diseases like HIV/AIDS. However, for countries with more
robust data the rise in malaria cases remains strong suggesting
that the scale of the malaria problem is escalating. Some of the
mentioned reasons for this resurgence include among others;
deteriorating health sectors within the region, a breakdown in
malaria control efforts, rising drug and insecticide resistance,
population movements and environmental changes favouring
increased malaria transmission. (7)
The rises in drug and insecticide resistance deserve special
mention. In Africa drug resistance, as we know it today, started
in East Africa during the late 1970s. Eventually we completely
lost chloroquine in the late 1990s, so we abandoned it during
the early years of this millennium. This delayed decision surely
caused many unnecessary deaths. Today we face a mounting wave of
SP resistance (8). Surely we
cannot afford more disastrous delays in policy changes. Although
there are many important questions in malaria control that are
begging for answers, including whether there is enough knowledge
about the disease and its determinants; whether there are enough
tools, or adequate resources and whether governments and
populations of disease-endemic countries are adequately
prepared? As important as these questions are, can we afford to
neglect investing sufficiently in the fight against Africa’s
leading public health enemy?
Some success
stories
Amid the
malaria deaths and sufferings, progress is being made. As said
earlier, African countries in 2000 committed themselves to
providing by the end of 2005 prompt and effective treatment and
insecticide-treated nets (ITNs) for 60% of the people at highest
risk of malaria and intermittent preventive treatment (IPT) for
60% of pregnant women. Initially, implementation of these
measures was severely limited by a shortage of resources for
procurement of commodities. But the situation in some countries
is improving. Some countries have reached or exceeded at least
some of these targets with recent increases in funding from new
sources. Most remaining countries are now poised to begin
scaling up, although substantial challenges remain.
With respect to
prompt and effective treatment, surveys have shown that on
average half of African children with fever are treated with an
antimalarial drug, but most of these treatments involved
chloroquine, against which resistance of the P. falciparum
parasite is very high. Increasing availability of artemisinin-based
combination therapy (ACT), a new and highly effective treatment
against falciparum malaria, is expected to improve treatment
outcomes within the next few years. By the end of 2004, 23
African countries had changed their national drug policy and
adopted ACTs.
With respect to
progress on prevention, the number of ITNs distributed has
increased
10-fold during
the past 3 years in more than 14 African countries. Subsidized
or free-of-charge ITN distribution has proved successful in
increasing coverage of the most vulnerable populations.
In most African
countries, many more households have mosquito nets not treated
with insecticide than ITNs. Scaling up of insecticide
re-treatment services will therefore also be an important factor
in increasing ITN coverage. The recent introduction and
manufacture of permanently treated nets, is expected to greatly
improve overall efficacy and effectiveness.
Efforts to
prevent the silent but significant burden of asymptomatic
infections in pregnant women residing in areas of stable malaria
transmission have been revitalized through partnerships between
malaria and reproductive health programmes. A total of 11
African countries, in addition to scaling up delivery of ITNs to
pregnant women, are now in the process of implementing
intermittent preventive treatment (IPT ) for pregnant women.(9)
New techniques
against an old scourge
Over the
last three decades there has been considerable interest in
research and development of malaria vaccines. The research
results obtained revealed that malaria vaccine candidates would
differ not only in their biological properties, but also in
their eventual applications: pre-erythrocytic stage vaccines,
also called sporozoite vaccines would generally prevent malaria
infections, asexual stage malaria vaccine candidates also
called blood stage vaccines would prevent disease, and the
sexual stage (gametocytes) malaria vaccine candidates which are
also referred to as transmission blocking vaccines would block
malaria transmission.
There is
clearly need to take advantage of ongoing advances in scientific
research especially in biotechnology and related endeavours to
develop the badly needed malaria vaccines. In order to sustain
such efforts and ensure their eventual deployment in malarious
communities it is absolutely essential that African researchers
participate fully in the creation of the new products so as to
ensure their progress in the entire product development
pipeline. An examination of the malaria vaccine development
process however reveals that all malaria vaccine discoveries,
patenting, pre-clinical testing, are undertaken in well
endowed northern institutions. Similarly the current Good
Manufacturing Practice (c-GMP) manufacture of test products is
restricted to the north. Even early phase malaria vaccine
testing is carried out in the north. Only products that are
safe in very preliminary testing are tested in African
populations.
Capacity
building
Achieving
victory over malaria in Africa requires a new internationally
funded effort dedicated to training and supporting a critical
mass of African malaria researchers for their parallel
involvement with researchers in the North for successful
implementation of new research findings for reversing the
situation in malaria endemic countries.
Although
there are several dozen malaria research institutions in Africa
only a handful of those with strong historical links to northern
institutions are ever involved in the testing of malaria vaccine
candidates. Institutions lacking such links, most of which are
owned by African ministries of science and technology, or
ministries of health, or African universities though better
placed to translate new knowledge from research into effective
intervention tools, are often short of essential personnel,
equipment and infrastructure and are therefore avoided in
product development. The need to strengthen these neglected
sites is obvious.
Malaria R & D
For too long
the global community has been reluctant to invest sufficient
resources in fighting malaria, leaving it near the bottom of the
world’s health agenda. However, with the recent gradual increase
in international awareness of the problem, malaria is now on the
agenda in the health community, in the political arena and also
in the international financial community.
In 1997, the Multilateral
Initiative on Malaria (MIM), an alliance of agencies,
institutions, and governments, was formed to maximize the impact
of scientific research through capacity building in Africa and
global collaboration. The following year, WHO, the United
Nations Children's Fund (UNICEF), the UN Development Program,
and the World Bank launched Roll Back Malaria (RBM) Global
Partnership to coordinate efforts in fighting malaria. RBM today
involves 90 countries, companies, and other organizations. It
recently published its “World Malaria Report 2005” on progress
toward halving the burden of malaria by 2010.
Multilateral
Initiative on Malaria
The
Multilateral Initiative on Malaria (MIM) is a global alliance of
organizations and individuals, funding partners and four
autonomous constituents comprising the MIM Secretariat, MIM/TDR,
MIMCom and MR4. Its aim is to maximize the impact of scientific
research against malaria in Africa, through promotion of
capacity building activities and facilitating global
collaboration and coordination (10).
The MIM
alliance has played to the emergence of a growing body of
reference research institutions staffed by well-trained national
scientists. MIM support has had a critical role in enabling
well-rounded teams and partnerships to emerge. Most of the
scientists supported by MIM ever since its inception are now
holding key posts in academia, health ministries and
international organizations, where they are helping shape
national and international malaria agendas and also facilitating
improved and effective malaria control in Africa.
MIM is also
contributing to sustainable research capacity in Africa by
providing mechanisms for communication and information sharing (MIMCom),
opportunities for collaborative /multicenter research (MIM/TDR),
access to well-defined, standardized reagents (MR4) and
dissemination of information regarding research opportunities
and findings through the MIM Pan-African Malaria Conferences (MIM
Secretariat).
International
donors recently pledged $3.7 billion to The Global Fund for
AIDS, Tuberculosis and Malaria (GFATM) for 2006 and 2007. The
amount represents about half of the $7 billion it says it will
need to fund all of its programs for the two-year period. GFATM
spends nearly three-quarters of all money spent on malaria
control, including drugs and bed nets, and has committed about
$1 billion toward that end over the next two years. In 2004, it
switched its support from general antimalarials to the purchase
of ACTs by governments receiving its grants. Over the next two
years, GFATM is expected to provide about 145 million ACT
treatments (11)
According to WHO, since GFATM
began disbursing funds in 2003, the demand for combination
therapies based on artemisinin has increased rapidly and led to
a drug shortage in late 2004. To ensure the quality of drugs,
WHO and UNICEF established a mechanism to prequalify
manufacturers; WHO is now calling on countries to use only
WHO-approved ACTs.
The G8 got
behind an £800m fund to battle malaria; the Bill and Melinda
Gates Foundation announced still more money to hunt down a
vaccine against this disease. Many other philanthropic
organization and institutions have emerged to lend hands in the
battle against malaria. Such august institutions include GSK,
Welcome Trust, Forgarty International Centre (FIC) of the of the
US National Institutes of Health (NIH), London School of Hygiene
and Tropical Medicine (LSHTM), African Malaria Network Trust
(AMANET), Multilateral Initiative on Malaria (MIM), Malaria
Vaccine Initiative (MVI), European Malaria Vaccine Initiative (EMVI)
and the list continues.
Conclusions and
Challenges
Where we do we
go from here?
Malaria
is an important social, economic, and developmental problem
affecting individuals, families, communities, and countries. The
best chance for successfully combating the disease requires a
collaboration not only of those responsible for control and
research but also many other sectors, including for example
agriculture, industry and commerce, transport, judiciary,
education, youth, gender and children and of course finance and
planning.. In research south-south, south-north, and north-north
collaborations are crucially important. In this regard MIM
presents itself as a worthwhile initiative.
MIM is calling
for new, innovative and practical ways of improving research
training in Africa. Among ideas being nourished is the
initiative that would focus on competitively awarded long-term
grants that would be dedicated to developing new “centres of
excellence” in malaria endemic areas of Africa. These centres
would serve as hubs for training new scientists and assembling
interdisciplinary teams for conducting major malaria research.
In addition, an African malaria research and control forum
will be established to translate malaria research results into
action, which will be coupled with renewed advocacy to promote
malaria awareness to the general public and among policy and
decision so that they increase goodwill and investments in
malaria research and control.
The MIM
Secretariat has been ably hosted by the Wellcome Trust
(1997-1999), the Fogarty International Centre (FIC) of the US
NIH (1999-2002) and lately by Stockholm University and
Karolinska Institutet (2003-2005). The African Malaria Network
Trust (AMANET) whose mission is to promote capacity
strengthening and networking of malaria R&D in Africa is hosting
the MIM Secretariat from January 2006 to December 2010.
References
1. Abuja
Declaration and the Plan of Action:
http://www.rbm.who.int/africansummit2000.html
2. Greenwood
BM et al. Mortality and morbidity from malaria among children in
a rural area of The Gambia, West Africa. Transactions of the
Royal Society of Tropical Medicine and Hygiene, 1987,
81(3):478–486
3. Roll
Back Malaria (2004) Malaria in Africa:
http://www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm
4. Sachs
J, Malaney P. The economic and social burden of malaria. Nature,
2002, 415: 680–685
5. Malaria
Site: History of Malaria Parasite and its Global Spread.
Available:
www.malariasite.com/malaria/history_parasite.htm
6. Malaria
Research & Development. An Assessment of Global Investment.
Available:
www.malariaalliance.org/PDFs/RD_Report_complete.pdf
7. Nchinda
TC, Malaria: A Reemerging Disease in Africa. Emerging Infectious
Diseases, Vol. 4, No. 3, July–September 1998
8.
World Health
Organization (2001), Drug resistance in malaria.
9. World
Health Organization, World Malaria Report 2005
10.
Multilateral
Initiative on Malaria (MIM):
www.mimalaria.org
11.
The Global Fund for
AIDS, Tuberculosis and Malaria (GFATM):
http://www.theglobalfund.org/en/media_center/press/pr_050823.asp
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