Roll Back Malaria Progress & Impact Series
Defeating Malaria in the Americas, Europe, the Middle East and the Pacific
1. Malaria remains a public health problem in 51 countries outside of Africa, particularly affecting poorer populations.
- Malaria remains a public health problem outside of Africa. It leads to an estimated 34 million cases and 46 000 deaths among a population at risk of 2.5 billion people. The level of malaria risk can vary enormously. It can be as high as in parts of sub-Saharan Africa, with cases and deaths concentrated in children under five years of age, or 1000-fold lower where cases and deaths occur according to the degree of exposure. Both Plasmodium falciparum and P. vivax parasites occur in great frequency. Diagnostic testing to determine the specific parasite and using the appropriate drug are critical. Malaria outside Africa is also characterized by greater mosquito vector diversity. Different vectors may have widely different breeding, feeding, and resting behaviours. Vector control interventions need to adapt to specific vector characteristics in a locality.
- Poorer populations are more likely to be affected. Poorer populations are more likely to live in rural areas in housing that offers little protection against mosquitoes. Furthermore, they are less likely to have access to mosquito nets or indoor residual spraying (IRS). They also tend to live further away from health facilities that can offer effective diagnostic testing and treatment and be less able to afford quality treatment.
- Malaria imposes costs on society which go beyond the costs to individuals and families affected by the disease. Productivity of businesses and government is reduced because of employee work time lost due to illness, and extra costs are incurred in preventing, diagnosing, and treating malaria. Malaria can discourage investment and trade-markets may be undeveloped owing to traders' unwillingness to travel to and invest in malaria-endemic areas. A country's tourist industry may remain undeveloped due to the travelers' reluctance to visiting malariaendemic areas.
2. Progress in defeating malaria has been substantial.
- Funding for malaria control has increased. Since 2003, international funding for malaria control has risen by more than eight-fold primarily because of the growth in funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria, which accounted for approximately 88% of the US$ 300 million of international funds disbursed for malaria control outside of Africa in 2010. A further 8% of international funding was from the World Bank and another 2% from the Australian government. The growth in international funding for malaria control has been matched, in some instances, by increases in domestic spending.
- Malaria control programmes have been expanded. The increased funding has enabled worldwide implementation of malaria control interventions, including long-lasting insecticidal mosquito nets (LLINs) and IRS for the prevention of malaria, and rapid diagnostic tests (RDTs) and ACTs for the diagnosis and treatment of malaria. The largescale implementation of interventions against malaria has led to widespread reductions in malaria cases and deaths and a shrinking of areas affected by malaria.
- The number of malaria cases and deaths has decreased. A total of 34 countries outside of Africa have reduced cases by more than 50% since 2000. Malaria death rates have decreased by 30% outside of Africa and four countries have been certified as free of malaria since 2007 (Armenia, Morocco, Turkmenistan, and the United Arab Emirates). The World Health Organization (WHO) European Region is aiming for elimination of malaria across the entire region by 2015 and P. falciparum transmission has already been eliminated from the region. Another 17 countries are in the pre-elimination or elimination phases of malaria control and on the brink of eliminating malaria from within their boundaries.
3. Further progress is possible but major challenges lie ahead.
- Mechanisms for the delivery of malaria interventions have been developed. In most countries outside of Africa, delivery mechanisms have been established for mass distribution of LLINs and ensuring access to diagnostic testing and treatment in remote communities. Partnerships among different organizations involved in malaria control have, under the Roll back Malaria (RBM) umbrella, been established, to gain economies of scale and ensure that WHO policies for prevention, diagnosis, and treatment of malaria are disseminated to implementing partners and activities are coordinated to ensure a more rational allocation of resources.
- Progress has been substantial in countries with fewer malaria cases and deaths but slower in countries where the bulk of the disease burden lies. The 34 countries that halved their malaria case numbers between 2000 and 2010 accounted for only 14% of all non-African cases in 2000 (8.3 million cases out of 59 million estimated). Greater attention is needed to reducing the burden of malaria in countries where the problem is greatest.
- As malaria decreases it is increasingly concentrated in marginalized populations. Ethnic, religious, and political minorities are particularly affected as are migrant workers and populations living in less developed border regions. It is more challenging, and more costly, to offer services to these populations because of geographical accessibility, security, or political concerns.
- As malaria decreases, P. vivax malaria - which is more difficult to control - becomes more prominent. As malaria control is intensified, the number of cases due to P. falciparum falls more quickly than those of P. vivax so the proportion of cases due to P. vivax increases. Although P. vivax infections are less likely to lead to severe malaria and death it is more difficult to control because it has a dormant liver stage which cannot be detected with existing diagnostic tests and can only be eliminated by administering primaquine which must be taken daily over 14 days. Primaquine can produce serious side-effects (hemolytic anaemia) in patients who have more severe forms of glucose-6-phosphate dehydrogenase (G6PD) deficiency. The development of a low-cost and accurateRDT for G6PD deficiency would be an important advance for the control of vivax malaria.
- As disease incidence decreases populations are more prone to epidemics. As the incidence of malaria is reduced, naturally acquired immunity to the disease (which is at best partial) decreases. Although new infections are less likely to occur they can rapidly lead to illness, which can be severe, and they can more easily spread from one person to another. A high level of commitment is needed to maintain control programmes even once success has been achieved.
- Unique diversity in behaviour of the mosquito vectors presents additional challenges. These mosquitoes are diverse in their biting and resting habits and their living and breeding habitats. For example, some efficient vectors live and breed in forested regions and bite and rest outdoors and are therefore not easily controlled by insecticide-treated mosquito nets or IRS.
- Resistance to the latest antimalarial medicines has emerged in South-East Asia. P. falciparum resistance to artemisinins has been detected in Cambodia, Myanmar, Thailand, and Viet Nam. Although the large majority of patients with delayed response to artemisinins are currently still being cured when treated with an ACT, resistance needs to be contained in existing hotspots before it is spread around the world and the ability to treat P. falciparum malaria is lost worldwide. No other antimalarial medicines are available at present with the same level of efficacy and tolerability as ACTs, and the earliest that replacement medicines could be available is 2016.
- Resistance to the insecticides used to control mosquitoes is widespread. Existing vector control tools are currently effective in the vast majority of settings. However, insecticide resistance has now been reported in 24 out of 51 countries with malaria transmission outside of Africa. Resistance to a class of chemicals known as pyrethroids, which are the most commonly used chemicals for IRS and the only class used on LLINs, seems most widespread. Resistance to these chemicals could severely impact the ability to maintain gains already achieved in reducing malaria as well as the ability to aim for further success.
- Future funding for malaria control in Asia, the Pacific, Americas, Middle East, and Europe is threatened. Many endemic countries are particularly reliant on the Global Fund, which accounts for the vast majority of international disbursements for malaria control. The Global Fund has recently experienced lower levels of replenishment than expected and Round 11 of the Global Fund's application process was cancelled to be replaced with a transitional funding mechanism which aims to sustain existing investments. Along with other donors, the Global Fund is increasingly focusing its funding on the poorest countries in Africa with the highest malaria burden. International funding for countries outside of Africa may therefore decrease.
4. What needs to be done?
To achieve the ambitious global goals of reducing the needless loss of life due to malaria, and to further reduce the malaria burden outside of Africa, governments, development partners, and other stakeholders should focus their attention on six priority areas.
- Bridge the funding gap. While more money is available for malaria control outside of Africa than ever before, these resources still fall short of the amount required for effective disease control. An unprecedented global fundraising effort is needed-mobilizing both existing and emerging donors-to ensure that all endemic countries move closer to elimination, marginalized populations are reached, and the efforts to contain drug and insecticide resistance are scaled up. It will also be critical that malaria-endemic countries benefiting from economic growth allocate more domestic resources to fight malaria, or the progress made in reducing malaria to date will be put at risk.
- Increase technical assistance and knowledge transfers. To defeat malaria, many endemic countries will also need significantly more technical assistance to strengthen their malaria response. When requested, technical partners should scale up assistance to ministries of health to support them in their efforts to design, evaluate, and update national malaria control strategies and work plans. Development partners should continue to help ministries of health provide health worker training and strengthen human resources for health. Particular attention should be paid to the design of interventions that help vulnerable groups be reached.
- Provide universal access to preventive interventions. Greater efforts are needed to provide protection to all those at risk of malaria, particularly in the most populous countries with the greatest numbers of cases and deaths. Attainment of this goal will be particularly challenging for those communities that are mobile or live in remote border areas. In some situations, novel vector control methods may be needed, such as insecticidetreated hammocks to protect those who work and sleep in forests overnight, or insecticidal mosquito coils to protect against outdoor biting mosquitoes. As prevalence rates fall and remain very low in many areas, new approaches need to be developed to tackle the last remaining cases.
- Scale up diagnostic testing, treatment, and surveillance. With the 2012 launch of WHO's T3: Test. Treat. Track initiative, malaria-endemic countries and donors are urged to ensure that every suspected malaria case is tested, that every confirmed case is treated with a quality-assured antimalarial medicine, and that the disease is tracked through timely and accurate surveillance systems. Scaling up these three interconnected pillars will provide the much-needed bridge between efforts to achieve universal coverage with prevention tools and the goal of eliminating malaria. It will also lead to a better overall understanding of the distribution of the disease, and enable national malaria control programmes to most efficiently direct available resources to where they are needed. T3 scale-up will enable affected countries to deliver a better return on investment on malaria funding received from international donors.
- Step up the fight against drug and insecticide resistance. The double threat of drug and insecticide resistance imperils recent gains in malaria prevention and control. Increased political commitment and new sources of funding will be needed to tackle these challenges. WHO has made global strategies available to address both drug and insecticide resistance. The Global Plan for Artemisinin Resistance Containment was released in January 2011, while the Global Plan for Insecticide Resistance Management in malaria vectors was issued in May 2012. These plans should be fully implemented by governments and stakeholders in the global malaria community to preserve the current tools of malaria control until new and more effective tools become available. Contributions from the research community and industry partners will be fundamental to tackling these emerging threats.
- Strengthen regional cooperation. Malaria can be defeated only if governments scale up regional cooperation efforts to strengthen the regulatory environment for pharmaceuticals and work together on removing oral artemisinin-based monotherapies and counterfeit medicines from markets. Countries also need to collaborate on managing the supply chain for malaria commodities and share information about drug and insecticide resistance patterns. In a world where malaria is increasingly confined to border areas-and where cross-border migration represents a major source of new malaria infection-regional cooperation is also critical for the development of cross-border strategies that are inclusive of marginalized
Governments have already made a number of commitments in the UN General Assembly and the World Health Assembly, through the governing bodies of WHO regional structures, and through a range of regional cooperation platforms, such as the Union of South American Nations (UNASUR) and the Association of Southeast Asian Nations (ASEAN). However, stronger political commitment will be needed to provide universal access to all key malaria interventions and to move closer to malaria elimination. With malaria designated as one of the key priorities of the UN Secretary General's five-year action agenda (2012–2017), there is an unprecedented opportunity to end the unnecessary suffering caused by this disease.
5. What can be gained?
- The burden of a senseless, preventable tragedy can be lifted. Scaling up malaria control efforts has been proven to reduce illness and death, especially among the poorest populations outside of Africa. This relieves some of the most vulnerable populations of a significant illness that causes disruption to schooling, work, and, at the worst, death.
- Considerable long-term impact and financial savings can be achieved both in endemic countries and globally. Protecting the tools we have by working to contain emerging drug and insecticide resistance will have cost implications in the near term for which many malaria-endemic countries will need support. However, investment now will result in significant savings in the long run, improving the sustainability and public health impact of malaria interventions, not only in countries affected but globally.
- Health systems can be strengthened. Improving the malaria response-at both the national level and in larger regions-will boost the capacities of health systems to improve the treatment of other febrile illnesses and will help to direct financial resources where the funds are most needed. Strengthening health infrastructure and improving health information systems for malaria will strengthen countries' overall capacities to respond to future public health threats, while also helping bridge existing health inequalities.
- Large areas of the world can be free of malaria in the foreseeable future. Four countries outside of Africa have been certified free of malaria since 2007. Another 17 are in the pre-elimination or elimination stage of malaria control and poised to eliminate malaria soon-removing the threat of disease from 74 million people currently at risk. If elimination is attained in these countries it would represent a historic achievement to be remembered for decades to come and set the course for eventual eradication of this ancient disease.
Find out how your country is doing from the infographic, which shows the estimated number of malaria cases each year, the "probable and confirmed" cases, as well as the current phase of the malaria response in each contry.
View RBM interactive infographic [Interactive PDF]
Defeating Malaria in the Americas, Europe, the Middle East and the Pacific
Download report : [in English]
Policy Brief [in English]
Press release [in English]
RBM video news release RBM: Saving lives in the Asia-Pacific [posted on RBM YouTube]
Video address of UN Secretary General Ban Ki-moon [posted on RBM YouTube]
Interactive PDF Malaria in Asia Pacific