Africa: Malaria in Africa: Why Most Countries Haven’t Beat It Yet

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Malaria remains one of the most devastating parasitic diseases affecting humans. In 2020 there were around 241 million cases and 672,000 deaths related to malaria. This is a sharp increase from 2019.

One reason it is so persistent is that the malaria parasite has a very complex life cycle. It involves many different developmental stages and multiple hosts (mosquitoes and humans).

And in Africa, what adds to the challenge of controlling malaria is that the continent is home to some of the most efficient malaria vectors. These include Anopheles gambiae and An. funesto. In addition, the malaria parasite species Plasmodium falciparum, the dominant species in Africa, is the most lethal. It is responsible for the majority of malaria cases and deaths, 80% of which occur in children under the age of five.

The World Health Organization (WHO) recognized these factors when it excluded Africa from its first Global Campaign to Eradicate Malaria, which ran from 1955 to 1969.

Since then, there have been many advances in malaria control. These include long-lasting insecticide-treated nets, rapid malaria diagnostic tests, and artemisinin-based combination therapies (ACTs) for the treatment of malaria.

But malaria elimination remains a challenge. Only two African countries, Algeria and Morocco, have been certified malaria-free by the WHO.

There are many reasons why elimination targets remain out of reach. In this article we highlight four: poverty, human movement, resistance and climate change.

Poverty

The limited progress towards malaria elimination is not surprising considering that some of the worst malaria-affected countries in Africa are also some of the poorest countries in the world.

Malaria is both a cause and a consequence of poverty. Therefore, the disease will continue to be a major problem in Africa, if more is not done to improve the socio-economic situation of communities affected by malaria. Eliminating poverty to improve the health and well-being of all is part of the millennium goals and sustainable development. This should be a priority for the governments of countries where malaria is endemic.

Mobility

Africa has one of the fastest growing populations, with a high level of mobility. Marginalized and vulnerable populations are some of the most mobile groups within Africa. They travel great distances through countries with different intensities of malaria transmission.

Human mobility is strongly associated with the global spread of infectious diseases, as evidenced by the recent outbreaks of COVID-19, Ebola, and monkeypox. This presents a challenge to malaria elimination aspirations in Africa.

Malaria parasites and mosquitoes do not respect country borders, so malaria services must be expanded to mobile and marginalized populations. Universal access to effective malaria diagnostics and treatment will reduce the burden of malaria by decreasing onward transmission.

Endurance

One of the greatest threats to eliminating and eradicating malaria is the emergence and spread of resistance to insecticides, diagnostics and drugs.

Both malaria vectors and parasites have proven to be highly adaptable. They have rapidly developed mechanisms to survive and multiply in the presence of insecticides and antimalarial drugs, respectively.

Insecticide resistance is widespread throughout the African region. It reduces the effectiveness of strategies based on vector suppression, such as long-lasting insecticide-treated nets and indoor residual spraying.

To extend the effective shelf life of available insecticides, the WHO has provided new guidance in its manual for integrated vector management. The manual highlights the importance of routine entomological surveillance to determine the type of vectors present, changes in vector behavior, and the insecticide susceptibility status of the vector. All of this information can guide effective vector suppression if it is available in time.

Getting the diagnosis and treatment right also depends on having a strong surveillance system. The system must be capable of generating near real-time efficacy data to enable rapid evidence-based decision making. The need for this type of routine surveillance has become even more urgent as African malaria parasites have developed mutations that allow them to evade detection by the most widely used rapid diagnostic tests on the continent. These undetected cases will go untreated, which could sustain further transmission. The result will be a huge increase in malaria cases, serious illness and potentially death.

In addition to becoming invisible to rapid diagnostic tests, P. falciparum parasites in many West and Central African countries have become resistant to artemisinins. This is a component of the most widely used antimalarials in Africa, the ACTs. The spread of artemisinin-resistant parasites will potentially increase the number of cases and deaths, repeating the devastating trend seen when drug-resistant parasites previously emerged. The loss of ACT would severely delay elimination efforts, as no new WHO-approved antimalarials are currently available. Efforts are needed to prevent the spread of artemisinin-resistant parasites through strong surveillance and containment responses.