Disease Prevention and Control / Communicable Diseases / Malaria
World Malaria Report 2005 (WHO Roll Back Malaria Department & UNICEF) | ||
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Full Text (293 pp, PDF) - Roll Back Malaria Publications |
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Executive SummaryProgress in the Americas |
Meeting increased demand & sustaining support | This is the first comprehensive report by Roll Back Malaria (RBM) partners on the status of malaria worldwide and on countries' progress to control the disease through effective treatment and prevention. The report is based on the best information that was available to the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) at the end of 2004 from routine reports, household surveys and special studies. Malaria remains a major global problem, exacting an unacceptable toll on the health and economic welfare of the world's poorest communities. During the past 4–5 years, however, substantial progress has been made in initiating and scaling up programmes to provide prevention and treatment to those who are most affected by this devastating disease. During the 1980s and 1990s, the burden of malaria increased in Africa. The reasons for this increase were resistance to commonly used antimalarial drugs, the deterioration of primary health services in many areas and the emerging resistance of mosquitoes to insecticides used for vector control. During the past decade, malaria also resurged or increased in intensity in South-East Asia after interruption of eradication efforts, and re-emerged in several Central Asian and Transcaucasian countries. Most countries did not start implementing programmes to provide access to the tools and strategies recommended by RBM until 2000. In many countries in Africa where the burden of malaria is greatest, scaling up access to treatment and prevention began even more recently. It is therefore too soon to determine whether the global burden of malaria has increased or decreased since 2000, given available data and scientific methods. Not until several years after high coverage with malaria prevention and treatment has been achieved will the worldwide impact on mortality be measurable. Some countries have already made and demonstrated progress in reducing malaria. The regional summaries that follow show progress in scaling up malaria control throughout the world since 2000. Regional progress in the Americas in access to treatment and prevention Malaria transmission occurs in 9 countries of the region that share the Amazon rainforest and in 8 countries in Central America and the Caribbean. Population movements associated with gold mining and forestry work have resulted in isolated epidemics. All affected countries use IRS and/or larviciding in focal areas at risk. Nine countries include ITNs in their national control strategies. Based on demonstrated chloroquine resistance, 8 of the 9 Amazon countries have recently changed national drug policies to use ACTs for the treatment of falciparum malaria. Chloroquine has retained its efficacy for treatment and prophylaxis against falciparum malaria in Central America north of the Panama Canal, the Dominican Republic and Haiti, and for treatment of vivax malaria throughout the region. A programme of "focalized treatment" consisting of improved treatment and IRS in focal areas successfully interrupted malaria transmission throughout much of Mexico, while the rational utilization of insecticides keeps costs low. Meeting increased demand and sustaining support for malaria control The estimated cost for supporting the minimal set of malaria interventions required to effectively control malaria is around US$ 3.2 billion per year for the 82 countries with the highest burden of malaria (US$ 1.9 billion for Africa and US$ 1.2 billion elsewhere). Only a fraction of that sum is available. Financial support and commitment to malaria control have increased since the inception of RBM. However, most of this increase has occurred during the past 2 years, and there remains a huge resource gap, especially in high-burden countries. At present, according to available data, governments in malaria-affected countries provide the main source of funds for national malaria control programmes. In 2002–2003, governments provided 71% of total funds in Africa, 80% in Asia, and 96% in the Americas. Despite these investments by national governments, the poorest countries tend to have the highest burden of malaria, and national funding commitments are unable to fill the gap between what is needed and what is available. Thus, sustained and increased donor assistance will be required for the foreseeable future. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), which began disbursement for malaria control in 2003, is an important international funding source. The GFATM disbursed more than US$ 200 million in 2003–2004 to 28 countries in Africa, 15 countries in Asia and 4 countries in the Americas. Approved commitments for malaria control for 2005–2006 total US$ 881 million. ACTs, the most effective available treatments against falciparum malaria, are 10 to 20 times more costly than chloroquine, the former mainstay of therapy. The demand for ACTs has increased rapidly since the GFATM began disbursing funds to countries. In 2004, this surge in demand resulted in a shortage of artemether-lumefantrine (Coartem®), the first ACT prequalified by WHO. Scaling up production of artemisinin—the raw material needed to produce ACTs—is a high priority for RBM. Improved forecasting of medication needs and financial commitment by countries will be crucial if the pharmaceutical companies manufacturing ACTs are to step up production. With respect to prevention, grants from the GFATM that were approved in 2003–2004 are expected to provide at least 108 million ITNs to countries. Sources of information relied on for global RBM monitoring include reports from national malaria control programmes, household surveys, drug efficacy monitoring at sentinel sites and health information systems. National malaria control programmes provide regular overviews of local malaria control strategies and policies, financing of programme activities and service delivery activities. Although reporting on programmatic indicators is not fully standardized across regions and varying control strategies, this information is useful for understanding changes in programme performance. Household (community-based) surveys provide the most relevant data on coverage with ITNs and access to malaria treatment. The national Multiple Indicator Cluster Surveys supported by UNICEF and the Demographic and Health Surveys conducted by Macro/Measure with support from the United States Agency for International Development at five-year intervals in many countries provide most data points. In 2004, RBM developed the Malaria Indicator Survey package for use in monitoring trends to increase coverage of malaria prevention and treatment. The Malaria Indicator Survey can be used to conduct household surveys in the absence of other surveys, or to fill gaps within the interval between subsequent Demographic and Health Surveys or Multiple Indicator Cluster Surveys. Surveys using this approach will be highly useful in preparing future world malaria reports. The next round of Multiple Indicator Cluster Surveys, to be conducted in 30 African malaria-endemic countries in 2005–2006, is expected to provide additional reliable information on increases in intervention coverage. Drug efficacy monitoring has in most regions greatly improved with the establishment of surveillance systems, sentinel sites and standardized study protocols within the past few years. These efforts are helping countries in regular updating of national drug policies, and they should continue to be expanded and supported. For countries in South-East Asia and the Americas, data from national health information systems are generally believed to provide a useful indication of trends in malaria cases and deaths. To improve the interpretation of health information systems data, their completeness should be assessed routinely in all countries using standardized methods. In most African countries, only a minority of patients who are ill with malaria are seen in medical facilities, thus health information systems data do not paint a reliable, let alone complete, picture. Here, major investments in health systems will be required before the utility of health information systems for monitoring disease trends can even be assessed, and population-level data are indispensable. In addition to all-cause under-5 mortality, the prevalence of childhood anaemia and malarial parasitaemia could be useful survey-based burden indicators. The goal of the RBM Partnership is to halve the burden of malaria in endemic countries by 2010. This report shows clear progress in scaling up antimalarial interventions in many countries. In Africa, several countries will reach at least some of the targets set by African heads of state in Abuja in 2000. It is clear, however, that there is much work to be done. The strengthening of countries' health-care systems—and of monitoring and evaluation—is paramount. At present it is too early to assess the impact of the recent scale-up of malaria prevention and treatment, but there are good reasons to believe a measurable reduction in morbidity and mortality should start to become apparent in the second half of the decade.
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