1. Malaria in Africa A Brief Overview

2. Learning Objectives 1.Describe the epidemiology of malaria in SSA 2.Understand the burden of malaria in Africa 3.Describe global efforts to control malaria (control, pre-elimination, elimination) 4.Describe the different types of malaria interventions

3. What causes malaria? Malaria is a parasitic and infectious disease, caused by parasite genus Plasmodium (Plasmodia) 5 main species of malaria parasites that infect humans: –Plasmodium falciparum –Plasmodium vivax –Plasmodium malariae –Plasmodium ovale –Plasmodium knowlesi

4. Malaria Transmission Cycle RecipientVector Parasite Blood meal Habitat/Environment/human Mosquito cycle Eggs Larva Pupa Adult Parasite cycle In mosquito In human Temperature Rainfall Humidity

5. Malaria Vectors Parasite is transmitted through the bite of infective female Anopheles mosquito during blood meal Anopheles species – 60 out of a total of 400 are relevant in malaria transmission

6. Host Factors Affecting Transmission Age: Children (particularly <5 years) are at high risk in endemic countries Sex and pregnancy status: Sex is not a major factor but pregnant women are at higher risk of and have greater susceptibility to malaria Location of residence: In epidemic-prone areas, all age groups are susceptible to malaria

7. Host Factors Genetic Factors Hemoglobin S (HbS)/ Sickle cell trait reduces the severity of P. falciparum infections Negative Duffy Antigens (on red blood cells) reduce susceptibility to P. vivax infections, as seen in West Africa Glucose-6-phosphate dehydrogenase deficiency (G6PD) protects against malaria

8. Environmental Factors Temperature affects Sporogonic cycle Gonotrophic cycle Survival Larval stage development Parasite will not develop at temperatures <16°C High relative humidity lengthens the life of the mosquito (Relative humidity >60 % needed for survival of adult Anopheles) Ideal conditions: Mean temperature 20-30°C Relative humidity of at least 60%

9. Environmental Factors Strong Winds Prevent egg-laying Extend mosquito flight range to infect more people Rainfall Adequate rains and distribution create mosquito breeding places Excessive rains destroy breeding places and sweep away larvae Increased humidity enhances mosquito survival Rainfall data can indicate probable vector presence and survival, potential for malaria transmission Altitude No transmission at high altitude

10. Global Distribution of Malaria No risk – light grey, Unstable grey – medium grey Stable risk – Grey, Endemicity – continuum yellow to red

11. Poverty – malnutrition, access to ITNs and treatment Poor sanitation Poor housing – not protected, not properly sited Occupation – working at night and sleeping outside Education – knowledge of transmission and ability to control malaria with available resources Wars and large-scale population movements Social and Economic Factors

12. Malaria and Poverty

13. Malaria and malaria-related illnesses account for ~20% of all deaths in children <5 Approximately 30-40% of out-patient visits to hospitals and 10-15% of all admissions are due to malaria Community-level case management occurs in up to 80% of malaria cases in some areas Burden of Malaria in Africa

14. Required health expenditure 15% of national budget (Abuja declaration) USD 12 billion per year in direct losses, Loss of 1.3% of GDP growth per year for Africa. Around 40% of public health spending in SSA Household spending : >10% of yearly (Africa) 35.4 million Disability Adjusted Life Years (SSA) Source: Global Malaria Action Plan (2008) Economic Cost of Malaria

15. Malaria Transmission/Distribution in Africa

16. Risk Stratification

17. Efforts to control and eliminate malaria

18. Control versus elimination Control: Reducing malaria morbidity and mortality to a locally acceptable level through deliberate efforts using the preventive and curative tools available today Elimination: Reducing to zero the incidence of locally acquired malaria infection in a specific geographic area as a result of deliberate efforts, with continued measures in place to prevent reestablishment of transmission. After three years in this state, countries can request malaria-free certification from WHO

19. History of Global Malaria Control Efforts –1950s: Start of global malaria eradication program Malaria was eradicated from many countries –1960s: Eradication program stopped Insecticide and drug resistance Poor infrastructure, particularly in Africa Financial constraints –1970s and 80s: Little attention to malaria and a shift of focus from eradication to control

20. Renewed Global Commitment to Fight Malaria Malaria reemerged as a major international health issue in the 1990s Global malaria control strategy adopted in 1992 Roll Back Malaria 1998 Abuja Declaration 2000 Strong political commitment and partnership

21. Key Malaria Targets & Goals African Summit on Roll Back Malaria, Abuja, Nigeria –At least 60% coverage of the population with appropriate prevention and treatment Millennium Development Goals –MDG 6: Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases –MDGs 1, 3, 4 & 5 -- also malaria-related World Health Assembly 2005 –Ensure reduction in malaria burden of ≥ 50% by 2010 and ≥ 75% by 2015 Roll Back Malaria Partnership Global Malaria Action Plan –By 2010: 80% coverage with interventions; by 2015: universal coverage, preventable mortality near zero & 8-10 countries achieve elimination of malaria

22. The Global Malaria Action Plan (GMAP) The GMAP outlines the RBM Partnership’s vision for a substantial and sustained reduction in the burden of malaria in the near and mid-term, and the eventual global eradication of malaria in the long term, when new tools make eradication possible

23. GMAP Objectives Objective 1. Reduce global malaria deaths to near zero by end 2015 Objective 2. Reduce global malaria cases by 75% by end 2015 (from 2000 levels) Objective 3. Eliminate malaria by end 2015 in 10 new countries (since 2008) and in the WHO Europe Region

24. The status of global efforts as of 2012 79 countries in the control stage 10 countries in the pre-elimination stage 10 countries in the elimination stage 5 countries preventing re-introduction

25. Coverage of Interventions

26. ITN Ownership An average of 53% of households in sub-Saharan African countries have at least one ITN in 2012 66 million ITNs were delivered to sub-Saharan Africa in 2012, whereas ~150 ITNs are needed each year to protect all people at risk. Source: World Malaria Report, 2011

27. Number of ITNs delivered by manufacturers to countries in sub-Saharan Africa, 2004–2012 Source: UNICEF global databases 2010, from MICS, DHS and MIS. Note: Dates of national surveys are indicated next to the country. Source: World Malaria Report 2012

28. Disparities in ITN Use Similar proportion of males and females report sleeping under an ITN in surveys. Urban residents are more likely to sleep under an ITN than rural residents. A lower proportion of older children (5-19) slept under an ITN than younger children (under 5) and adults

29. Proportion of population at malaria risk protected by ITNs or IRS, sub-Saharan Africa, 2011 Source: World Malaria Report 2012

30. Proportion of suspected malaria cases attending public health facilities that receive a diagnostic test, 2000–2011 Source: World Malaria Report 2011, National Surveys Source: World Malaria Report 2012

31. Proportion of children under 5 with fever receiving a blood test for malaria, 2010-2011 Source: World Malaria Report 2011, adapted from Littrell, M., et al. Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 2011, 10:327 Source: World Malaria Report 2012

32. ACTs delivered to the public and private sectors, 2005-2011 Source: World Malaria Report 2011, adapted from Littrell, M., et al. Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 2011, 10:327 Source: World Malaria Report 2012

33. Ratio of RDT and microscopy performed to ACTs distributed, African Region, 2006-2011 Source: World Malaria Report 2011, adapted from Littrell, M., et al. Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 2011, 10:327 Source: World Malaria Report 2012

34. Proportion of women attending antenatal care receiving the second dose of IPTp, 2011 Source: World Malaria Report 2012

35. How do we know when we have succeeded?

36. References Africa Malaria Report. Geneva, World Health Organization, 2006. Global Malaria Action Plan. Geneva, Roll Back Malaria Partnership, 2008 Households that have at least one ITN, Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007. Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region, WHO-AFRO, 2007. Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007. The President's Malaria Initiative Progress through Partnerships: saving lives in Africa Second Annual Report. Washington, D.C., PMI, 2008. World Malaria Report. Geneva, World Health Organization, 2008 World Malaria Report. Geneva, World Health Organization, 2009 World Malaria Report. Geneva, World Health Organization, 2010 World Malaria Report. Geneva, World Health Organization, 2011 World Malaria Report. Geneva, World Health Organization, 2012

37. MEASURE Evaluation is a MEASURE program project funded by the U.S. Agency for International Development (USAID) through Cooperative Agreement GHA-A-00-08-00003-00 and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership with Futures Group International, John Snow, Inc., ICF Macro, Management Sciences for Health, and Tulane University. Visit us online at http://www.cpc.unc.edu/measure.