W O R L D M A L A R I A R E P O R T 2 0 0 5: EXECUTIVE SUMMARY

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.

In 2000, African countries 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. Some countries have reached or exceeded at least some of these targets with recent increases in funding. 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. In addition, 22 countries had adopted and begun to implement the RBM-recommended strategy of home management of malaria for children under 5 years of age—which involves education and training of mothers and provision of pre-packaged high-quality medicines—in order to provide more prompt treatment for children in rural areas with poor access to facility-based care.

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. This is often linked to antenatal care and/or child immunization services, or national child immunization campaigns. Surveys conducted from 1999 to 2004, with the median survey year 2001, have shown that the median proportion of children under 5 years of age using ITNs was only 3% (ranging from 0.1% to 63% across 34 countries). There is, however, indication of rapid improvement. Surveys conducted in 2002–2004 showed remarkable increases in ITN coverage for children under 5 years of age in countries such as Eritrea (63%) and Malawi (36%). In selected areas of Senegal, household ownership of ITNs increased from 11% in 2000 to 41% by 2004. Updated, wide-scale assessments of ITN coverage are not yet available for most other countries.

Urban, relatively wealthy households are far more likely to own ITNs than rural and poorer households, in which people are at higher risk of malaria. Some African countries have succeeded in breaking this pattern. Programmes of highly subsidized ITN distribution through public health services in Ghana and Nigeria, and a national campaign of free ITN distribution alongside measles immunization for children under 5 years of age in Togo, resulted in high coverage rates in all population groups. 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.

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 IPT for pregnant women.

Malaria remains a significant problem in the Eastern Mediterranean subregion, especially in areas where, over the past 30 years, complex emergencies and the associated destruction of health systems have aggravated the disease situation. Since 1998–1999, regional expenditures on malaria control have increased. The main control strategies are access to prompt and effective treatment, indoor residual spraying (IRS), epidemic preparedness and strengthening of surveillance systems. These strategies have succeeded in halting or reversing the trend of increasing case rates in many countries. In a high-risk area of Yemen, for example, vector control and strengthened surveillance with active community participation have succeeded in reducing the number of malaria cases 10-fold since 2001.

Vivax malaria resurged in Central Asia and Transcaucasia, and falciparum malaria re-emerged in Tajikistan during the 1990s. Beginning in 2002, this region stepped up vector control through ITNs and IRS. Some countries also made considerable progress in surveillance methods and epidemic preparedness. Kyrgyzstan, for example, reinforced surveillance, used targeted IRS and improved case management in malaria-affected areas in response to a 2002 epidemic. These efforts are keeping malaria in check, although reported incidence remained around 10-fold higher in 2003 than in 1990. Sustained commitment and adequate financial support will be needed to prevent malaria from becoming a greater problem.

South-East Asia has the highest rate of drug resistance in the world, and multidrug resistance has contributed to the re-emergence of malaria in many areas, especially along international borders. Adults lacking immunity who work in forested areas or as migratory labourers are at high risk. Since 1998, all countries in the region have been routinely monitoring drug resistance. Out of 9 countries in this region, 6 have adopted ACTs as a national policy for first-line treatment of uncomplicated falciparum malaria. Challenges remain, however, for improving access to ACTs in private clinics, pharmacies and shops and in reducing the use of counterfeit and substandard drugs. Improving capacity for laboratory diagnosis of malaria through microscopy or rapid diagnostic tests is also a major focus of malaria control efforts, particularly in remote areas where malaria risk is high.

All countries in South-East Asia use IRS and/or larviciding for vector control in selected areas most affected by malaria, and all include epidemic preparedness and surveillance among national control strategies. Use of IRS, chiefly with pyrethroid insecticides, and ITN distribution, which started recently in most countries, have been associated with reductions in reported case rates in selected areas. Indonesia and Sri Lanka, for example, have had substantial successes. Sri Lanka, which uses focused IRS in high-transmission areas, larviciding and ITN distribution, ceased having epidemics after 1992 and reduced malaria incidence to the lowest level observed since 1967. In a high-risk area on central Java, Indonesia, improved diagnostic and treatment services, including outreach to poor rural areas and ITN distribution, halted and reversed a major malaria epidemic in 2001. This project also provided the impetus for re-establishment of malaria monitoring and surveillance systems.

In the Western Pacific subregion, malaria control was revitalized in the mid-1990s following a resurgence of the disease related to economic decline, large-scale population movement and breakdown of disease control and health-care services. Key strategies are vector control through ITNs and IRS, epidemic preparedness and prompt and effective treatment. Rates of reported cases fell gradually between 1992 and 2003. In Viet Nam, the number of malaria deaths declined rapidly after introduction and effective use of ACTs for first-line treatment. In a high-risk area of Malaysia, ITN distribution and improved diagnosis and treatment services offered by primary health-care volunteers reduced malaria incidence 28-fold between 1995 and 2003.

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.

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.

At the end of 2004, 107 countries and territories had areas at risk of malaria transmission. Some 3.2 billion people lived in areas at risk of malaria transmission.

An estimated 350–500 million clinical malaria episodes occur annually; most of these are caused by infection with P. falciparum and P. vivax. Falciparum malaria causes more than 1 million deaths each year. It also contributes indirectly to many additional deaths, mainly in young children, through synergy with other infections and illnesses.

Patterns of malaria transmission and disease vary markedly between regions and even within individual countries. This diversity results from variations between malaria parasites and mosquito vectors, ecological conditions that affect malaria transmission and socioeconomic factors, such as poverty and access to effective health care and prevention services.

About 60% of the cases of malaria worldwide, about 75% of global falciparum malaria cases and more than 80% of malaria deaths occur in Africa south of the Sahara. P. falciparum causes the vast majority of infections in this region and about 18% of deaths in children under 5 years of age. Malaria is also a major cause of anaemia in children and pregnant women, low birth weight, premature birth and infant mortality. In endemic African countries, malaria accounts for 25–35% of all outpatient visits, 20–45% of hospital admissions and 15–35% of hospital deaths, imposing a great burden on already fragile health-care systems.

Evidence continues to accumulate to support the view that adults infected with HIV, in addition to children under 5 years of age and pregnant women, should be targeted for malaria prevention and treatment. Malaria contributes synergistically with HIV/AIDS to morbidity and mortality in areas where both infections are highly prevalent, such as in Africa south of the Sahara. In addition to providing immediate health benefits, prevention and treatment of malaria may lessen transient increases in HIV viral load during malaria episodes and thus help limit the progression