SECTION II:

MALARIA CONTROL, BY REGION

I. AFRICA

• Parasitological species of malaria cases: P. falciparum 93%, P. vivax or P. falciparum/ P. vivax mixed 7%
• Principal malaria vectors: A. gambiae, A. funestus
• Estimated proportion of population at risk of malaria: 66% (21)
• Estimated contribution to the global burden of clinical malaria cases: 59% (2)
• Estimated contribution to the global burden of clinical falciparum malaria cases: 74% (2)
• Estimated contribution to the global malaria mortality burden: 89% (1)
• Main control strategies: prompt and effective treatment including home management of malaria, ITNs, IPT, IRS, epidemic preparedness

1. Disease burden

Africa remains the region that has the greatest burden of malaria cases and deaths in the world. In 2000, malaria was the principal cause of around 18%— 803 000 (uncertainty range 710 000–896 000)—of deaths of children under 5 years of age in Africa south of the Sahara (19). During the 1980s and the early 1990s, malaria mortality in rural Africa increased considerably, probably as a result of increasing resistance to chloroquine (18, 19). Malaria is also a significant indirect cause of death: malaria-related maternal anaemia in pregnancy, low birth weight and premature delivery are estimated to cause 75 000–200 000 infant deaths per year in Africa south of the Sahara (28). Malaria epidemics result in an estimated up to 12 million malaria episodes and up to 310 000 deaths per year in Africa (29).

In contrast to the endemic countries in Africa south of the Sahara, Egypt and Morocco have only residual malaria transmission and occasional imported cases. Their goal in controlling malaria is to eliminate the few remaining foci of transmission by 2006 (30). The remainder of this section focuses on countries in Africa south of the Sahara.

Burden on health systems

In Africa south of the Sahara, the case rates reported through national HIS represent only a minor fraction of the actual burden of malaria (31). Access to clinical care is poor, especially in the most rural areas where malaria transmission is most intense. Furthermore, reporting from facilities to districts and from districts to health ministries is incomplete, and completeness and timeliness vary between and within countries. Finally, in clinics most cases of malaria are diagnosed on the basis of clinical symptoms rather than on laboratory confirmation, which is rarely available at first-line health facilities.

Figure 2. Burden of malaria on health systems in Africa south of the Sahara, by subregion, 1999–2004 Proportion of outpatient visits, hospital admissions and hospital deaths due to malaria from national HIS data averaged from 2001 to 2003 or the 3 most recent years with available data since 1999 from countries in Africa south of the Sahara; proportion of children under 5 years of age with fever in the preceding 2 weeks from national DHS (11)and MICS (10) between 1999 and 2004 (median survey year 2000). Error bars indicate the standard deviation.

Given the incompleteness of case and death reporting from health facilities, the proportions of reported cases and deaths caused by malaria relative to the total number of cases and deaths from all causes are more informative indicators than absolute numbers of reported malaria cases and deaths. Across endemic countries, an average of 25–35% of all outpatient clinic visits are for (clinically diagnosed) malaria, both in children under 5 years of age and in other age groups. In these same countries, between 20% and 45% of all hospital admissions are caused by malaria. With high case-fatality rates due to late presentation, inadequate clinical management and unavailability or stock-outs of effective drugs, malaria is also a major contributor to deaths of hospital inpatients. The proportional malaria burden is somewhat lower in the Southern Africa subregion than in the Central, East and West Africa subregions (Fig. 2).

Especially among children under 5 years of age, malaria is an important contributor to demand for health care because of the high prevalence of fever in this age group. Throughout Central, East and West Africa, about 30–35% of children under 5 years of age report a fever in the 2 weeks preceding a survey (Fig. 2). The Integrated Management of Childhood Illness recommends, along with RBM, that in areas of high malaria endemicity all acute fevers in children under 5 years of age be treated presumptively with an antimalarial (32). Thus, although not all childhood fevers are in fact caused by malaria, these fevers do determine the demand for antimalarial treatments.

Although these data provide an indication of the continuing high burden of malaria on African health systems, annual reporting from countries to WHO is not complete enough to allow an evaluation of recent time trends.

All-cause under-5 mortality

In Africa south of the Sahara, all-cause under-5 mortality is an important indicator of the burden of malaria. Children in this age group are those most likely to develop severe disease and to be at risk of dying from malaria. In addition to the around 18% of all-cause deaths in African children under 5 years of age that are directly attributable to malaria (19), an even greater proportion of child deaths is probably indirectly related to malaria: repeated malaria infections contribute to the development of severe anaemia and make young children more susceptible to severe outcomes of other common childhood illnesses such as diarrhoea and respiratory diseases (33). In addition, malaria in pregnant women contributes to low birth weight, a major risk factor for infant mortality (34). Further demonstration of the importance of malaria as a contributor to deaths among young children is the series of community-randomized ITN trials that demonstrated a reduction in all-cause under-5 mortality by up to 25% (35). National household surveys provide more comprehensive data on all-cause under-5 mortality than is available for malariaspecific mortality, which is difficult to define and measure at a population-level with adequate specificity and sensitivity (19).

Throughout Africa south of the Sahara, the decrease in all-cause under-5 mortality that was apparent during the 1970s and 1980s levelled off in the 1990s (36) (Fig. 3). Besides HIV/AIDS, increased mortality caused by malaria in the 1990s compared with earlier decades is probably among the explanations for this trend (18).

Figure 3.Trend in all-cause under-5 mortality in countries in Africa south of the Sahara, by subregion, 1960–2002 ( 36)

2. Control efforts and progress towards Abuja coverage targets

At the African Summit on Roll Back Malaria in Abuja, Nigeria, in 2000, African heads of state committed themselves to halving the burden of malaria by 2010, by achieving a 60% coverage of all at-risk populations with suitable curative and preventive measures by 2005 (Box 1). However, few countries are likely to reach the 60% target for coverage of access to prompt and effective treatment for ITNs and IPT for protection of pregnant women by 2005 because, until very recently, control efforts remained too fragmented and major international investment materialized too late (37).

Around US$ 2 billion per year—of which US$ 1 billion is needed for ACTs—is estimated as needed to effectively combat malaria in Africa (38). Currently only about one quarter of this amount is available. However, financial support for programmes to prevent and treat malaria has increased rapidly over the past few years. Complemented by increased capacity development at all health system levels, through technical support to national control programmes and other avenues, progress is now likely to accelerate.

3. Coverage of mosquito nets and insecticide-treated nets

Increased national and international funds have boosted the deployment of ITNs. About half of the African countries have waived taxes and tariffs on nets, netting materials and insecticides. Since 2002, several countries started scaling up free of charge or highly subsidized provision of ITNs for children under 5 years of age and pregnant women (Table 6).

As a result, there has been a substantial increase in ITN coverage in several of these countries, according to household surveys conducted over time that measured either ITN usage by children under 5 years of age or household ownership of ITNs (Fig. 4).

Figure 4. Time trends in ITN coverage in selected African countries with multiple data points, 1999–2004 Data for Benin, Kenya and Zambia from national DHS or MICS ( 10, 11); data for Nigeria and Senegal from Netmark surveys in selected areas with malaria (12); data for Malawi from DHS in 2000 ( 11) and a nationally representative survey by the MoH in 2004. Symbols indicate survey data; lines indicate estimated linear time trends based on the survey data.

On an Africa-wide scale, it is more difficult to precisely describe the current level of ITN coverage or the progress in increasing ITN coverage. Of the 45 African countries where ITNs form part of the national malaria control strategy, 36 had a representative household survey that measured child usage of nets and/or ITNs at some point between 1999 and 2004, but most of these surveys were conducted in 2000–2001. According to available surveys, only Eritrea, in 2003, reached the Abuja target of 60% ITN usage (Fig. 5). For many other countries that started scaling up ITN distribution in 2001, no data point later than 2000 is available (Table 6). It should be noted that the data presented in figure 5 and Box 3 represent nationallevel outcomes, except for Eritrea. In countries where malaria risk is not universal, ITN usage in those areas at actual malaria risk might be higher than the national average. There is a need for additional high-quality household surveys to measure time trends in ITN coverage. Around 2007, more information will be available after another approximately 30 MICS and DHS planned in malaria-endemic African countries for 2005–2006 (10, 11).

Figure 5. Proportion of children under 5 years of age sleeping under mosquito nets and ITNs in African countries, by year of survey, 1999–2004 Data from national household surveys, except for Eritrea, which had a representative household sample survey in the three zobas with risk of malaria (39). For each country, the most recent national datapoint is presented.

Available surveys do indicate that coverage with any net is generally much higher (up to 10-fold) than coverage with ITNs: across all countries with data—taking the most recent survey point in each country—a median of only 11% of nets used by children under 5 years of age (range: 0–93%, 34 surveys) and a median of just 18% of nets owned by households (range: 1–79%, 10 surveys) were ITNs. Countries where ITN distribution was recently successfully scaled up include Eritrea, Malawi and Rwanda, where over half of nets used by young children were ITNs. A much larger number of untreated nets, compared to ITNs, are already available for atrisk populations, especially in West and Central Africa. This indicates that the provision of (re-)treatment of nets as a free public service is an important complement to the distribution of ITNs.

Countering inequities in ITN coverage

The cost of an ITN is a major barrier to ownership and usage for a large proportion of Africans who are among the poorest of the poor and also the most highly affected by malaria. Although the malaria burden is highest in rural areas and among the poorest people, ITN coverage tends to be generally higher in urban areas and in wealthier households. This is evident from the data from national surveys. Net and ITN possession and usage by children under 5 years of age are twofold to threefold lower in rural areas compared with urban areas. Net and ITN possession and usage are between twofold and eightfold lower in the poorest households compared with the least poor households (Fig. 6).

Figure 6. Median net and ITN possession (as % of households) or usage (as % of children under 5 years of age that slept under a net or ITN the night before a survey) in selected African countries by urban and rural division (a) and among the 20% poorest and 20% least poor households (b) Data from national household surveys conducted between 1999 and 2004: urban/rural: net usage from 36 surveys, ITN usage from 34 surveys, net possession from 17 surveys, ITN possession from 8 surveys; poorest/least poor households: net usage from 25 surveys, ITN usage from 25 surveys, net possession from 6 surveys, ITN possession from 4 surveys.

Social marketing and subsidized or free of charge distribution of ITNs for target groups can effectively reduce this inequity, as was recently illustrated in Ghana, Nigeria and Togo (Box 4). Since 2002, in deprived areas of Ghana and Nigeria, UNICEF-supported programmes have supplied highly subsidized ITNs to pregnant women and children under 5 years of age through routine public health services. A year after the programmes began, usage of ITNs by children under 5 years of age and pregnant women in rural areas was similar to or higher than that in urban areas. Net possession in Nigeria and net possession as well as usage in Ghana were equally high or higher in the poorest households compared with the least poor households (Fig. 7). Although no ITN coverage data from earlier years are available for Ghana and Nigeria, the contrast with less favourable coverage distribution patterns in neighbouring countries that lacked subsidized distribution programmes is clear (Fig. 6).

In contrast to these inequities between urban and rural areas and between poorest and least poor households, no gender inequities are evident: in available survey data, net and ITN usage were generally similar for boys and for girls.

Figure 7. Median net and ITN possession (as % of households) or usage (as % of children under 5 years of age) in Ghana and Nigeria in 2003 after programmes of intensified distribution of free and subsidized nets in deprived areas, by urban and rural division (a) and among the 20% poorest and the 20% least poor households (b) Data from national DHS surveys conducted in 2003 (11).

BOX 4. INTEGRATING INSECTICIDE-TREATED NET DISTRIBUTION WITH SCALED-UP IMMUNIZATION CAMPAIGNS IN ZAMBIA AND TOGO National campaigns of ITN distribution in combination with measles immunization conducted in Zambia in 2003 and in Togo in 2004 demonstrated an unprecedented successful approach of scaling up ITN coverage within only a few days. Zambia In 2003, the Zambian MoH, with support from UNICEF, the Canadian Red Cross and the Canadian International Development Agency, conducted a campaign integrating measles vaccination, ITN distribution, vitamin A supplementation and mebendazole treatment for intestinal worms in five underserved districts of Zambia. All households with children under 5 years of age were given an ITN. The Zambian Red Cross provided social mobilization and community education. According to a survey conducted after the campaign, this resulted in greater than 80% coverage for all interventions in the five districts, which had 89 000 children under 5 years of age (Fig. 8). As part of the high and universal coverage, ITN usage was scaled up in a rapid and equitable way, reaching the poorest and most vulnerable segments of the population. Under the platform of the national measles campaign, the delivery cost per ITN was only US$ 0.36 (and the production cost US$ 4.41 per ITN). Figure 8. Abuja target of 60% ITN usage was surpassed in 6 days in all five targeted districts of Zambia Togo A national campaign of ITN distribution, measles and polio vaccination and deworming treatment was conducted in Togo in December 2004. About 920 000 ITNs were distributed, or one per child under 5 years of age. Preceding the campaign, volunteers from the Togolese Red Cross Society conducted door-to-door and community social mobilization campaigns informing people about the importance of protecting their children and about the location of the vaccination and distribution centres. Through monthly home visits, Red Cross volunteers advise families on the proper use of the mosquito nets, and provide additional vaccinations and free ITNs to others at risk including pregnant women, neonates and immigrant children. In January–February 2005, staff from the Togolese MoH, the Togolese Red Cross Society and the Division of Parasitic Diseases at the United States Centers for Disease Control and Prevention, Atlanta, conducted a household survey to assess the increase in ITN coverage resulting from the campaign. Trained personal data assistants with geopositioning capacity mapped relevant sampling units. Across 12 sampled districts, covering all 6 country regions, around 2254 households with 2259 children under 5 years of age were interviewed. Preliminary results indicate that, on a weighted basis, the campaign increased possession of ITNs from 6% to 62% averaged over all households. An estimated 98% of households with a child under 5 years of age now have at least one ITN, of which approximately 95% were obtained from the distribution campaign. The campaign had the effect of equalizing ITN ownership rates between groups of different socioeconomic status, although all groups benefited greatly (Fig. 9). Under the innovative mechanism of delivering ITNs using the platform of measles immunization, the incremental cost of delivery was less than US$ 0.50 per ITN. Campaigns combining immunization with other life-saving interventions such as ITN distribution are expected to become a major contribution towards achieving the Millennium Development Goal for reducing child mortality and the Abuja target of 60% ITN usage in Africa. In 2005–2006, similar campaigns are planned for areas of southern Chad, Equatorial Guinea and Niger at risk of malaria. Figure 9. ITN ownership by households, before and after the integrated distribution campaign in Togo

4. Coverage of antimalarial treatment

About two-thirds of malaria-endemic African countries have changed their antimalarial treatment policy since 1998 in response to the emergence of drugresistant falciparum malaria; of these, 65% have done so since the Abuja Declaration of 2000. By the end of 2004, 23 countries had adopted ACTs in their antimalarial treatment policies (Box 7), while 22 countries had adopted home management of malaria in their national malaria control strategies, of which 11 are scaling up home management and 11 are piloting the strategy (Table 7).

Table 7. Countries that adopted and implemented the strategy of home management of malaria in Africa, by the end of 2004

In Africa, where the vast majority of malaria cases and deaths occur in young children, WHO recommends that all acute childhood fevers in areas of high malaria endemicity be treated presumptively with an antimalarial (32). Therefore, the proportion of young children with fever who received an antimalarial drug represents a relevant survey-based indicator of the coverage of antimalarial treatment among all malaria patients with prompt and effective treatment. Between 1998 and 2004, across 35 national surveys, the median proportion of children under 5 years of age that were treated with an antimalarial drug was 49.6% (range 3.0–68.8%) (Fig. 10). However, most of these antimalarial treatments could not be considered effective since: (i) 95% were with chloroquine, against which there is a high rate of falciparum malaria resistance (Fig. 10); (ii) a significant proportion were not started within 24 hours of the onset of fever, so not all treatments were necessarily given in sufficient time to prevent a possible progression into severe life-threatening malaria (Fig. 11); and (iii) the dosages typically taken might not always have been adequate for full parasitological cure, although dosaging was not measured in national surveys. For these reasons, the coverage with prompt and effective antimalarial treatment was probably much lower than survey data indicate. However, it is likely that the proportion of fevers treated with effective antimalarial regimens is now increasing in those countries that have recently implemented a change in drug policy to combination treatment. There are as yet no wide-scale survey data available to document this, but national DHS and MICS scheduled for 2005–2006 will include detailed, standardized questions on antimalarial drug treatments.

Strengthening of primary care for children under the strategy of Integrated Management of Childhood Illness is also expected to help improve the coverage of prompt and effective antimalarial treatment among children in Africa. As part of the strategy, prompt referral of sick children with defined danger signs from primary health facilities to the next level of the health-care system should improve the coverage of life-saving treatment for severe malaria (32). As of 2004, 38 countries in Africa south of the Sahara were implementing Integrated Management of Childhood Illness, of which 36% were in the early implementation phase and 58% in the expansion phase; among countries in the expansion phase, about one quarter had more than half of their districts implementing the strategy (37).

Figure 10. Proportion of children under 5 years of age with fever treated with any antimalarial or with chloroquine in countries in Africa south of the Sahara, 1999–2004 Data from most recent national household survey either DHS (11) or MICS (11). Median survey year is 2001.

Figure 11. Proportion of children under 5 years of age in selected African countries treated with an antimalarial starting within 1 day after onset of fever or later, 2003–2004 Data from most recent national household survey, either DHS (11) conducted in 2003 or 2004, and a survey by the MoH in 2004 for Malawi. In the Malawi survey, the coverage of antimalarial treatment starting more than one day after onset of fever was not measured.

5. Malaria prevention and treatment in pregnant women

In all subregions of Africa, well-timed antenatal clinic attendance is key for delivering the malaria prevention package to pregnant women, since surveys have consistently shown that at least two thirds of pregnant women in malaria-endemic countries use antenatal care, and most of them attend antenatal clinics at least twice (Fig. 12). Since approximately 40% of these women present for the first time to an antenatal clinic in the second trimester of pregnancy, the first dose of IPT could be given in time to most pregnant women.

Figure 12. Proportion of pregnant women in Africa who receive antenatal care at least twice, based on national surveys, by subregion, 1995–2004 Data are from the most recent DHS ( n= 29 surveys); median survey year is 2000.

While initially few countries were using antenatal care services for IPT, the integration of IPT into these services became part of the national malaria control strategy in 21 countries by the end of 2004. However, only 11 of these countries are at some stage of actually implementing IPT. In Kenya, Malawi, Uganda, United Republic of Tanzania and Zambia, implementation covers the whole country or scaling up towards countrywide coverage is on track.

Coverage of pregnant women with IPT using sulfadoxine–pyrimethamine, according to national surveys in Ghana, Kenya and Zambia, generally remains below 10% (Fig. 13). An exception is 47% coverage in Malawi, the first country to adopt IPT in its national malaria control policy. The interpretation of these data is complicated because some surveys measured the receipt of sulfadoxine–pyrimethamine specifically during antenatal clinic visits, while other surveys measured any usage during pregnancy regardless of the occasion or source; the latter would include both preventive and curative treatments and thus overestimate IPT programme coverage. Moreover, for both outcomes some surveys reported use of sulfadoxine–pyrimethamine regardless of the number of doses, while others reported coverage only for those women who received at least 2 doses during the pregnancy, which is the WHO-recommended frequency for IPT policy. Recent progress in standardizing assessment of IPT coverage in household surveys will address these inconsistencies.

Figure 13. Proportion of pregnant women receiving sulfadoxine–pyrimethamine based on national surveys conducted in African countries, 2002–2004 Median survey year is 2003 and includes countries where IPT implementation is currently underway or planned for the whole country. Surveys reflect DHS 2002 (Zambia), DHS 2003 (Ghana, Kenya) and MoH 2004 (Malawi). IPT was adopted in Ghana in 2004 and implementation began at the end of the year.

IPT coverage was fairly equally distributed between urban and rural areas and between less poor and poorer women, reflecting that antenatal clinic services are widely used among all socioeconomic levels of African populations and thus providing a major opportunity for delivery of IPT.

National-level surveys indicate that use of mosquito nets among pregnant women in malaria-endemic countries remains unacceptably low (Fig. 14). The proportion of pregnant women sleeping under a net (irrespective of the net’s treatment status) was a median of 15% (range 5.4–34.1%) across 10 surveyed countries. Coverage with ITNs was a median of 2.8% (range 0.5–31.4%) across 8 national surveys.

6. Coverage of indoor residual spraying

About half of the endemic countries, mainly in Southern and East Africa, include targeted IRS in their NMCP strategy. An increasing number of African countries use IRS for mosquito control, and the reported number of households or units sprayed rose from around 2.7 million in 1999 to over 4 million in 2003.

Figure 14. Proportion of pregnant women sleeping under a mosquito net and ITNs in countries in Africa south of the Sahara, based on national surveys, 2001–2004 Median survey year is 2003.

7. Coverage of epidemic detection and control

Of 17 countries that reported at least one malaria epidemic between 1999 and 2004 (totalling 119 epidemics), 9 report using a weekly surveillance system that allowed them to detect ongoing epidemics and, subsequently, to respond within 2 weeks (37).

8. Drug efficacy

Chloroquine failure rates were between 50% and 60% in East and Central Africa in recent years, respectively. In West and Southern Africa, typically between 10% and 30% of treatments with chloroquine fail (Fig. 15). These failure rates are similar to those in the 1990s, confirming that chloroquine resistance had already spread widely throughout Africa more than a decade ago. The fluctuation in median failure rates from 1994 to 2004 reflects that sites sampled for efficacy testing varied over the years: not every site was repeatedly sampled to track the actual local time trend (Fig. 15).

Resistance of P. falciparum against the most affordable alternative drug, sulfadoxine–pyrimethamine, is typically 10–20% in East and Southern Africa and around 10% in Central and West Africa (Fig. 16). The few available studies of chloroquine combined with sulfadoxine–pyrimethamine from just 6 countries show failure rates ranging from 3% in Comoros to 13% in Rwanda (Fig. 17). Amodiaquine resistance is found at low levels in East and Central Africa.

Figure 15. Treatment failure of chloroquine for falciparum malaria in Africa, by subregion, 1996–2004 Drug efficacy expressed as clinical treatment failure with 14-day follow up ( 9). Boxes indicate the 25th and 75th percentile of failure rates observed across available studies, error bars indicate the upper and lower adjacent values and the grey line in each box indicates the median. Excludes years with fewer than five studies.

Figure 16. Treatment failure of sulfadoxine-pyrimethamine in Africa by subregion, 1996–2004 Drug efficacy expressed as clinical treatment failure with 14-day follow up (9). Boxes indicate the 25th and 75th percentile of failure rates observed across available studies, error bars indicate the upper and lower adjacent values and the grey line in each box indicates the median. Excludes years with fewer than five studies.

Figure 17. Treatment failure of chloroquine+sulfadoxine–pyrimethamine in Africa south of the Sahara, by country, averaged over 1996–2004 Drug efficacy expressed as clinical treatment failure with 14-day follow up ( 9). Boxes indicate the 25th and 75th percentile of failure rates observed across available studies, error bars indicate the upper and lower adjacent values and the grey line in each box indicates the median. Excludes years with fewer than five studies.

9. Malaria and HIV/AIDS

Malaria and HIV/AIDS mutually reinforce each other and contribute synergistically to morbidity, mortality and burden on health systems. Especially in Southern Africa, where HIV is highly prevalent and malaria is unstable and therefore affects a relatively large proportion of adults, HIV infection has probably contributed to observed increases in malaria cases during the 1990s (40, 41).

In Central Africa, where large areas of countries have malaria transmission at high intensity, malaria is likely to be an important contributor to morbidity and mortality in HIV/AIDS patients.

In areas of unstable malaria transmission, HIV infection augments the risk of developing severe and fatal malaria (42, 43). In areas of stable endemicity, HIV infection among adult men and non-pregnant women increases the incidence of clinical malaria and its severity and case fatality (44). These effects are most pronounced in HIV/AIDS patients with advanced immunosuppression. Pregnant women who have high rates of both HIV and malaria infection are a particularly vulnerable group. Coinfected pregnant women are at very high risk of anaemia and malarial infection of the placenta, which contributes to poor birth outcomes (28).

Conversely, there is some evidence that malaria may exacerbate HIV infection. Acute malaria episodes temporarily increase viral replication and hence HIV viral load, which may accelerate disease progression and contribute to heterosexual HIV transmission (45). In addition, as an important cause of anaemia, malaria frequently leads to blood transfusions, which is a potential risk factor for HIV infection.

The increased disease burden resulting from coinfection with HIV and malaria highlights the need for better integration of health services for both diseases. HIVinfected adults should be targeted for free or subsidized distribution of ITNs (46). The recurrent non-malarial fevers in HIV/AIDS patients could cause considerable overuse of antimalarial drugs under the policy of presumptive antimalarial treatment of all acute fevers (47). To reduce costs and the risk of drug resistance, capacity for laboratory diagnosis of febrile disease should be increased in countries with high HIV prevalence and high malaria incidence. Prompt and effective combination treatment is particularly important for HIV-infected individuals who might be prone to treatment failure with conventional antimalarial drugs (48, 49). By preventing acute increases in viral load, good coverage of antimalarial treatment could contribute to limiting HIV disease progression and transmission (45).

EXECUTIVE SUMMARY
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COUNTRY PROFILES
Overview

ACCESS BY MAP

ACCESS BY COUNTRY LIST

COUNTRY DATA, BY REGION
Classification
Explanatory notes
Regional tables

MAPS

MERG [MERG website]

DEFINITIONS

GUIDELINES ON MALARIA CONTROL