Malaria Endgame: How the world is fighting the killer parasite

Mosquitoes have no passports and recognize no borders, but the environmental health officer at Kazungula Port Health Office 70-km away from the Victoria Falls at Livingstone, Zambia, has the seemingly impossible mandate to stop malaria sneaking in from across the border.

The borders of four countries – Zambia, Bostswana, Zimbabwe and Namibia – come close to meeting at Kazungula, where Dr Kenneth Banda zealously guards his country against an invasion by the malaria parasite, from a makeshift office inside a shipping container on the north bank of the Zambezi river.

“Everyone crossing the border is screened for fever using a thermal body scanner and those with fever are tested for malaria using a rapid diagnostic test,” he says. “If they are positive, an ambulance takes them to a clinic half a kilometre away, where they are treated, to stop the infection from spreading.”

One of the biggest threats to Zambia’s goal of becoming malaria-free is cross-border importation of cases from its eight neighbours – Democratic Republic of Congo, Tanzania, Malawi, Mozambique, Zimbabwe, Botswana, Namibia and Angola – which between them account for more than 20% of the world’s malaria cases.

“We get several cases of fever, but there is not much malaria here now compared to five years ago. The DR Congo in the north is a problem,” Dr Banda says.

Yet the landlocked country is staying the course.

“Eliminating malaria by 2021 is a legacy goal that will be achieved through several measures — indoor residual spraying before the rainy season, mosquito nets for every bedspace, legal powers to nurses to prescribe anti-malarial drugs for treatment, larva-source control in rivers, ponds and dams in remote parts, and strong cross-border initiatives with neighbours, among others,” says Chitalu Chilufya, health minister of Zambia.

A global effort

Sri Lanka and Kyrgyzstan were certified malaria-free in 2016, and 21 countries are on track to eliminate malaria by 2020, according to the World Health Organisation (WHO) World Malaria Report 2017, released this week.

Africa accounted for 90% of the 216 million cases, which has put the spotlight on Zambia’s “zambitious” goal to be malaria-free by 2021.

Globally, there were an estimated 5 million more malaria cases in 2016 than in 2015, with deaths hovering around 445,000, a similar number to the previous year, the report states.

“Progress since 2000 has proven that malaria control is one of the best humanitarian investments in the world today, creating $20 in economic benefits for every $1 invested. But to realise these benefits, we need to invest current resources more efficiently and expand overall financing, both by malaria-affected countries and donors,” says Martin Edlund, CEO of Malaria No More, a Seattle-based humanitarian organisation focused on malaria.

“This report presents a clear choice: either we do what is necessary to end this disease, or we risk backsliding on previous investments and letting malaria resurge at the cost of millions of lives and trillions of dollars in economic benefits,” Edlund says.

An estimated 75% of all malaria cases recorded in South-East Asia occur in India. To overcome the challenges that malaria poses, a multi-pronged approach, focusing on high-burden areas and vulnerable groups is essential, experts say. (HT File Photo)

Where we stand

An estimated 75% of all malaria cases recorded in South-East Asia occur in India. Weak surveillance is the biggest hurdle to elimination.

“Countries with weak malaria surveillance systems include India and Nigeria, two major contributors to the global burden of malaria, with 8 per cent and 16 per cent of cases, respectively, detected by the surveillance system,” says the WHO report. About 10.9 million people contract the infectious disease in India every year.

“To overcome the challenges that malaria poses, a multi-pronged approach, focusing on high-burden areas and vulnerable groups, and supporting some of the states in their efforts to eliminate malaria in the medium-term, is imperative,” said Dr Henk Bekedam, WHO’s representative to India. “Scaling up the use of long-lasting insecticidal nets, indoor residual spraying and other mosquito-control measures are important tools in this context.”

As important is getting the numbers right. “Robust surveillance and data collection is essential to end malaria and for India, the challenge is the large number of cases treated in the private sector, which are not reported to the government,” says Dr Benjamin Rolfe, executive director and CEO of Asia Pacific Leaders Malaria Alliance. “Cambodia registered a decline in malaria last year but it turned out it was because health workers were not reporting cases because they hadn’t been paid.”

Going micro

Work has begun, but it needs to be accelerated to meet India’s target to eliminate malaria by 2030. “We’re focusing on better surveillance and point-of-care diagnostics to capture more cases. Early diagnosis and effective treatment has helped in reducing deaths,” said Dr Neena Valecha, director of National Institute of Malaria Research at the Indian Council of Medical Research. “Involving the private sector, both formal and informal, is a challenge but efforts are on to build partnerships.”

With 80% of malaria cases occurring among 20% of India’s population in 200 high-risk districts, how India’s National Strategic Plan for Malaria Elimination (SPME) pans out will depend on how well states implement it.

Complicating matters is the emergence of a drug-resistant strain of the malaria parasite in south Vietnam. First identified in Cambodia in 2008, it has now become the dominant strain in parts of the Greater Mekong sub-region, which is close to India’s north-eastern border.

India reported its first chloroquine-resistant P. falciparum near the India-Myanmar border in 1973, and chloroquine-resistant P. vivax in 1995. Since then, resistance is so entrenched across India that only a fast-acting combination called artemisinin combination therapy (ACT) can treat malaria.

Despite challenges in India, public health specialists remain upbeat. “Setting a target is a start and India is on track to meet the goal,” says Dr Valecha.

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