Operationnal research - Preventing malaria
Progress in stagnation
After seven decades of commitments and particularly significant achievements since the beginning of the 21st century, the fight against malaria is in a worrying situation. Despite substantial strengthening of malaria control services between 2000 and 2015, contributing to a 27% reduction in the global malaria incidence and an almost 51% reduction in malaria-related mortality, in recent years progress has stalled. The COVID-19 epidemic, in addition to other challenges such as the emergence of insecticide and antimalarial resistance, low coverage of malaria control interventions, humanitarian emergencies and declining funding, have boosted epidemiological indicators. For example, according to the latest World Malaria Report (2021), there were an estimated 14 million more malaria cases in 2020 than in 2019 (241 million compared to 227 million). The number of deaths is also increasing: an estimated 69,000 more people died of malaria in 2020 than in 2019 (627,000 compared to 558,000). Almost two-thirds (47,000) of the additional malaria deaths resulted from disruptions of malaria prevention, diagnosis and treatment services during the pandemic.
The WHO African Region continues to bear a disproportionate brunt of the global malaria burden: in 2020, Africa accounted for 95% of all malaria cases and 96% of malaria deaths. Children under five accounted for around 80% of all malaria deaths in the region. Just over half of all malaria deaths worldwide were recorded in four African countries: Nigeria (31.9%), the Democratic Republic of the Congo (13.2%), the United Republic of Tanzania (4.1%) and Mozambique (3.8%). More generally, it has been noted that the HBHI (high burden to high impact) countries (those where there are concerted efforts to increase impact), are the countries that are losing the most ground.
Significant gaps in prevention and treatment
In addition, the gaps in prevention and preventive treatment remain too great. In fact, although simple malaria cases are relatively easy to prevent and treat, the approaches being implemented are failing to achieve good coverage rates, due in part to a lack of closely targeted activities. The private health sector is not sufficiently included in the malaria control strategy, although it does provide a significant share of malaria screening and treatment.
Between 2000 and 2020, the percentage of children under five and pregnant women sleeping under treated mosquito nets increased from 3% to 49%; extraordinary progress yet half of the population at risk for malaria in Africa is still not protected by this preventive tool. In addition, access to preventive treatment for pregnant women and children under five remains too low, which partly explains the increase in malaria-related mortality. In this regard, coverage of three doses of IPTp in pregnant women in the 38 African countries that have adopted this preventive regimen increased from 11% in 2010 to 16% in 2015 and 32% in 2020 but remains well below the 80% target set by the international community. In terms of seasonal malaria chemoprevention (SMC), the number of children who received at least one dose in the 13 countries in the Sahel highly affected by seasonal malaria has increased very rapidly, from less than 0.2 million in 2012 to 33.5 million in 2020, but more than one third of children living in the region still do not have access to it.
With regard to treatment for children, various surveys conducted in sub-Saharan Africa show that between 10% and 25% of children who have requested artemisinin-based combination therapy (ACT) malaria treatment do not receive it.
Finally, it should be noted that the worrying changes in the climatic, political and security context in many malaria-endemic countries are factors that hamper the effectiveness of interventions and in some regions bring them to a standstill.
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World Malaria Report 2021, p.8
The other third (22,000 deaths) reflects the recent change in the methodology used by WHO to calculate malaria mortality, regardless of these disruptions. The new methodology to identify cause of death has been applied to 32 countries in sub-Saharan Africa, accounting for about 93% of all malaria deaths worldwide. Application of this methodology has revealed that, every year since 2000, the disease has taken the lives of far more African children than previously thought.
The 10 African countries are Burkina Faso, Cameroon, Democratic Republic of Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and Tanzania, to which India is added (these countries are also commonly called the 10+1).
For example, malaria cases in HBHI countries decreased from 155 million to 150 million from 2000 to 2015 but increased to 163 million in 2020. In the same countries, malaria deaths decreased from 641,000 to 390,000 between 2000 and 2015, rose to 444,600 in 2020.