Questions and Answers for the World Malaria Report 2010

Q. What are the biggest differences between the findings in this report and the one in 2009?

Many more insecticide treated mosquito nets (ITNs) have been delivered to countries in Africa; 289 million between 2008 and the end of 2010. More people are protected by indoor residual spraying; 75 million in 2009. More than a third of malaria cases reported from the public sector in Africa in 2009 had been confirmed with a diagnostic test compared to less than 5% at the beginning of the decade. More courses of artemisinin-based combination therapy (ACTs) have been delivered to the public sector; 158 million in 2009 although it is still uncertain if this is sufficient to meet needs The report highlights two countries that have rapidly expanded access to diagnostic testing nationwide; Lao People's Democratic Republic and Senegal, preventing the unnecessary use of hundreds of thousands of courses of ACTs annually. More countries are reporting decreases of more than 50% in cases and deaths since 2000, 11 in Africa and 32 in other regions. Two countries were certified free of malaria in 2010 (Morocco and Turkmenistan) and for the first time, no locally transmitted cases of Plasmodium falciparum were recorded in the WHO European Region. Against a broad background of success, resurgences in malaria were noted in 2009 in three countries (Rwanda, Sao Tome and Principe and Zambia).

Q: Why has the mortality from malaria gone down? How many children are still dying from malaria?

Mortality from malaria has decreased since the beginning of the decade. Much of this decrease is believed to be due to the increased availability of ITNs and indoor residual spraying with insecticides and better access to effective treatment with ACTs, particularly in the second half of the decade. Socio-economic improvements in many countries in Africa have also brought down the number of deaths from all causes in children in children under 5 and are likely to have also had an impact on malaria. The World Malaria Report 2010 estimates that 791,000 persons died from malaria in 2009, 91% of those deaths occurred in sub-Saharan Africa, and 85% occurred in children less than 5 years of age.

Q: Where has there been progress in the fight against malaria and where are there still challenges?

Many countries have continued to show progress in fighting malaria as noted above. In general, countries with smaller populations at risk have shown more progress. This is partly because they have received more money per person at risk of malaria. In some cases, it is because also their surveillance systems are better and thus better able to provide evidence of decreases in malaria.

Of some concern is recent resurgences of malaria in three countries that had previously shown considerable success in reducing malaria; Rwanda, Sao Tome and Principe and Zambia. The reasons for these increases are not known with certainty, but likely reflect some combination of natural variation and lapses in control measures, including delays in replacing worn-out ITNs. The increases in malaria cases highlight the fragility of malaria control and the need to maintain control programmes even if numbers of cases have been reduced substantially. They also highlight the need for monthly monitoring of disease surveillance data, both nationally and sub-nationally. Many countries in sub-Saharan Africa currently have inadequate data to monitor disease trends, and greater efforts are needed to strengthen routine monitoring systems. Major epidemiological events could be occurring in other countries that are not being detected and investigated.

Q. The report says that by the end of 2010 enough nets had been delivered to cover 76% of the 765 million people at risk from malaria and that 42% of households own at least one net. How do you explain the difference in these numbers and what happened to all the nets?

The number of ITNs delivered by the end of 2010 will be sufficient to cover 76% of the population at risk assuming that two persons are sleeping under each net. The percentage of households owning at least one net (42%) is an estimate for the middle of 2010 (1 July). It appears to take six months or more for a net arriving at a port to be distributed through warehouses, and ultimately through to households by mass campaigns or routine distribution systems such as antenatal clinics. Hence, the mid-year estimate of household ownership of ITNs reflects the ITNs delivered to countries six months before or earlier. A number of other factors may also contribute to this apparent difference, including: the underestimation of ITN ownership as measured through household surveys (as respondents have an incentive to under-report ITN ownership); the fact that many households have more than one net, while others may have none; the wearing out of long-lasting insecticide treated nets more quickly than the generally used estimate of 3 years; the estimate of 1 net per 2 persons may be inadequate in some settings depending on housing type, family size, and sleeping patterns.

Q. What is the latest on the spread of Plasmodium resistance to antimalarials and mosquito resistance to insecticides?

Resistance of P. falciparum to artemisinins was confirmed at the Cambodia–Thailand border in 2009. Since 2008, containment activities to limit the spread of artemisinin-resistant parasites have been ongoing. Despite the observed changes in parasite sensitivity to artemisinins, the clinical and parasitological efficacy of ACTs has not yet been compromised. Nonetheless, the use of oral artemisinin-based monotherapies, or using an ACT containing a partner medicine that is not locally efficacious, increases the risk of development or spread of artemisinin resistance. By November 2010, 25 countries were still allowing the marketing of oral artemisinin-based monotherapies and 39 pharmaceutical companies were manufacturing these products. Most of the countries that still allow the marketing of monotherapies are located in the African Region and most of the manufacturers are in India.

Current methods of malaria control are highly dependent on a single class of insecticides, the pyrethroids, which are the most commonly used compounds for IRS and the only insecticide class used for ITNs. The widespread use of a single class of insecticide increases the risk that mosquitoes will develop resistance, which could rapidly lead to a major public health problem, particularly in Africa, where chemical vector control is being deployed with unprecedented levels of coverage and where the burden of malaria is greatest.

Q: What is happening with donor and country funding for malaria prevention, control and elimination?

The amounts of money disbursed by international agencies are estimated to have increased to their highest levels ever in 2009, at US$ 1.5 billion. Funding by endemic country governments also appear to be rising. However, the total amounts of money available for malaria control remain substantially lower than the resources required to achieve global targets, estimated at more than US$ 6 billion for the year 2010. Funds committed to malaria control from international sources appear to have leveled-off at US$ 1.8 billion in 2010. It is uncertain whether this leveling-off will also be reflected in money disbursed in 2010; initial evidence suggests that disbursements have continued to rise but not at the same paces as in previous years. If the tremendous gains in malaria control are to be sustained, then it is critical that the Global Malaria Action Plan be fully funded in order to achieve international malaria control targets and reach the health related Millennium Development Goals.

http://www.who.int/malaria/world_malaria_report_2010/en/index.html