Meet the Experts #1: The Malaria Burden and Interventions: Where are we? World Malaria Day 2017

INSIGHTS! WITH PUBLIC HEALTH AND MALARIA EXPERT- DR KOLAWOLE MAXWELL

According to the WHO World Malaria report 2016, nearly half of the world’s population is at risk of malaria and due to wide spread of malaria control interventions, malaria is endemic in 91 countries as at 2016 from 108 countries in 2000. The Global Technical Strategy 2016-2030 was set and aimed at accelerating progress towards malaria elimination.

Malaria is a life threatening disease caused by the Plasmodium parasite transmitted to people through bites by the female Anopheles mosquitoes known as the vector. Worthy to note, malaria is preventable and curable.

In commemoration of the World Malaria Day 2017 (April 25), WHO and global actors are advocating for prevention; expanded access to proven and cost-effective prevention tools which have contributed immensely to the reduction of the global burden with the theme ‘’End Malaria for Good’’. The WMD also presents an opportunity for countries to appraise their level of achievement, highlight areas of support and mobilise needed support.

To get a first-hand view of ‘where we are’ with the Malaria burden and intervention, we caught up with Dr. Kolawole Maxwell to give us expert insights on the journey so far and experience working in development and on Malaria interventions. Dr. Maxwell is a Medical Doctor and has engaged in the Public Health sector for over 2 decades; research and development especially in the areas of Malaria, contributing to key interventions and policy reviews. He talks us through achievements and gaps especially in the sub-Saharan Africa region.

Global burden of Malaria

WHO reports has confirmed the malaria burden has reduced by one-third from 2000 to 2015 with 400,000 deaths per year although about 90% of this death is in sub Saharan Africa (and about 25% in Nigeria). Hence the concentration in higher prevalent regions to tackle the malaria burden. There has been records of the burden reducing to pre-elimination phase like in countries like Cape Verde.

Key Intervention and Impact

2 main aspects; prevention and case management. Prevention has been through mass campaigns for Long Lasting Insecticide Net (LLIN) distribution reaching a wider scale of population. WHO also recommends IRS (Indoor Residual Spraying) but the roll-out is at initial stages in Nigeria. Other prevention interventions include larval source and environmental management. Malaria control as a public health intervention depends on evidence. There has been cases where evidence has shown vector and parasites changing behavior, and the mosquitoes perching on the walls after a blood meal hence the effectiveness of LLIN and IRS. But some mosquitoes are now biting outside which could make our tools ineffective. In retrospect the parasites has also developed resistance to drugs in many places for example Chloroquine. This led to the change in treatment policy in Nigeria from Chloroquine to ACT (Artemisinin-based Combination Therapy) in 2005.

Depending on epidemiology of malaria, there might be need for different interventions or combinations of interventions which include but not limited to;

•      Very endemic areas however need scale up of LLIN interventions for malaria control to break transmission. 
•           In Sahel regions where there is no Sulphadoxine Pyrimethamine (SP) resistance to engage in and scale up Seasonal Malaria Chemoprevention (SMC) to prevent deaths during high transmission periods.
•            Scale up for case management ensuring proper diagnosis and treatment for malaria cases
•         To reduce burden, there needs to be increased effort towards prevention intervention to reduce and prevent re-infection.

Rural coverage

This is discussed when looking at areas of higher burden which could be mostly in the rural regions. According to the National Malaria Indicator Survey (NMIS) 2015 there was a record of higher coverage in the rural than urban area for LLIN interventions. Case Management however has attained less coverage as this is more dependent on the Health systems. This could be responsible for higher burden in the rural but this needs to be evidenced.

Elimination and Eradication

These are terms used for standard definition of the phases. Control phase refers to parasite prevalence of about 50% and above, eradication phase is 10%, pre-elimination and elimination phases is <10% and prevention of re-introduction is 0%. What is recommended to be done by WHO is universal scale – up intervention when you are in control phase, eradication is mostly surveillance, pre-elimination and elimination works towards guarding against re-introduction of infection through increased surveillance which includes Tracking, Testing and Treatment (3Ts). An example is Malaria in Pregnancy (MIP) where immunity increases with the number of pregnancy.

Most interventions can be linked to control phase. Elimination on the other hand is possible but dependent on time frames and there are examples from countries that have eliminated Malaria.

Malaria intervention and Health Systems Strengthening

In the bid to achieve pre-elimination and elimination phases; case management and surveillance, there is a lot of interaction with the Health System. The pre-elimination phase targets every infection to address potential cases of re-infection. There are other areas that needs to be integrated into broader Health Systems.

Looking at the future for Malaria interventions and tackling the burden

-          Preparation for different tools as experience has shown the vector has defiled tools that worked in the past for example Chloroquine and Dichloro-Diphenyl-Trichloroethane (DDT) in some countries particularly in Africa.

-          Scaling up existing tools is essential to break transmission. Both existing and new ones and deploying them based on evidence. Nationwide scale – up for all tools might not be ideal any longer.

-          Collaboration across countries to address transmission due to movement across boarders and regions.

-          Looking at areas of costs and the interventions. Basically, efficiency and effectiveness. Efficiency can be in terms of cost and other parameters

High Point and Low Point working with the development sector

High point would be on impacting lives, looking back from my work in Kaduna- Northern Nigeria, the Support to National Malaria Programmes in Nigeria, contribution to other work in Africa and to the global fight on Malaria, and how people are affected especially positively.

But there are the low point’s of course which could be frustrating, looking at sustainability, funding, and conflicts of interests of the different actors and so on.

An encouraging factor with it all is that every little mileage or effort contributes to achieving the goals in what we do.

To young and upcoming experts

‘’check your values and keep your value’’.

There is also concern around paying attention to local capacity and maximizing efforts. Particularly in Nigeria, for developing experts to be encouraged to maximize their skills where most needed and perhaps in their countries especially after gaining some training and expertise.

Lastly, it is advisable to get a Malaria test  before treatment and avoid self-medication for malaria.

Let's kick malaria out- Always test before treatment