Q: Although there are many stakeholders in the fight against malaria, yet malaria continue to kill a child every 2 minutes. What is the reason for that?
- In addition to being the third-highest infectious disease killer of children, malaria traps families in a cycle of illness, suffering and poverty. It is estimated that malaria cost up to 1.3 per cent of GDP in Africa every year. As of 2018, malaria’s direct costs are estimated to be $12 billion USD per year.
- Since 2010 there has been a plateau in the funding of the global malaria response and since 2015 we have seen a slow and steady increase in cases (sometimes as much as 5 million additional cases per annum).
- Malaria is resurging in complex emergencies (e.g. Northern Nigeria, Yemen, South Sudan, DRC).
- Even when major inroads have been made against the disease as a result of stepped-up funding and programming. success is fragile and closely tied to sustained support. To achieve the goal of a malaria-free world, annual spending needs to more than double from the current level to $6.6 billion by 2020. In 2017, the global total of international and domestic funding for malaria control and elimination was $3.1 billion – less than half of what is needed.
- Despite major gains, sub-Saharan African countries are falling short of the global target of universal use of treated mosquito nets by children
There are nevertheless important opportunities to reverse these trends:
- Sleeping under insecticide-treated mosquito nets (ITNs) on a regular basis is one of the most effective ways to prevent malaria transmission and reduce malaria related deaths. It is particularly effective when used by children and their constant use by at least 80% of the population can lead to up to 20% reductions in all-cause child mortality. This translates into up to 6 lives saved for every 1000 children sleeping under a mosquito net. Since 2000, production, procurement and delivery of ITNs, particularly Long Lasting Insecticide Treated Nets (LLINs) has accelerated, resulting in increased household ownership and use. Since 2000, over 1 billion ITNs have been distributed in Africa and the 2 billionth net was distributed during 2019.
- Most countries have made considerable progress in the past decade and successfully increased ITN use among children in an equitable way. This was largely due to free distribution campaigns that emphasized poor and rural areas. The success of this strategy has been reflected in an increased use of ITNs by vulnerable populations.However, household ownership of ITNs/LLINs is uneven between and within countries – ranging from less than 20 per cent to approximately 90 per cent. The percentage of sub-Saharan African households with at least one ITN was 53 per cent in 2018, thus, nearly half of households where ITNs are the main method of vector control did not have access to a net. Additionally, only 40 per cent of households had sufficient ITNs for all household members which is drastically short of the universal access of 100 per cent to this preventive measure.
- Artemisinin-based combination therapy (ACT) is the most effective antimalarial therapy for P. falciparum, the most lethal malaria parasite and the one most pervasive in sub-Saharan Africa. By the end of 2014, most African countries, where Plasmodium (P.) falciparum is endemic, had adopted ACTs as national policy for first-line treatment. However, in surveys since 2013, fewer than half of children treated for malaria were actually receiving an ACT. Although the practice is changing, other less effective antimalarial drugs are still commonly used to treat malaria. Treatment of malaria in children with ACT is low in sub-Saharan Africa with just over one third of children treated with antimalarial drugs receiving the first-line drug
- Malaria is an important entry point for community and health systems strengthening – two of UNICEF’s flagship programmes. High quality, effective malaria case management is often the starting point on increasing equitable access to holistic care for the febrile child which has the potential to greatly reduce childhood morbidity and mortality from malaria, pneumonia, diarrhea and severe acute malnutrition (iCCM). Antimalarial treatments are more likely to be ACTs if children sought treatment at public health facilities or via community health workers than if they sought treatment in the private sector.
UNICEF is helping to further the fight against malaria by:
- engaging policymakers on ensuring their national malaria control strategies take into account the needs of the most vulnerable and that they are devoting national resources to complement donor resources
- supporting communications campaigns to ensure families receive the message about protecting themselves from malaria by sleeping under a bednet every night, seeking care when their children are febrile and providing a holistic package of care that encompasses the main killers of children.
- using innovative means to support children and mothers with the means to reach health posts such as voucher schemes and family health care kits;
- and ensuring facilities and communities have access to well-trained workers, drugs and bednets.
Q. You mentioned Nigeria as the highest burden malaria country – why is that the case and why isn’t more being done to lower the incidence in the country? Recognizing Nigeria’s challenges, what is the current UNICEF effort to improve malaria interventions in the country?
Nigeria is one of the “High Burden, High Impact”[1] countries. It is therefore top of the list in terms of investments and support to bring down the malaria burden in the country. Nigeria’s malaria funding and Program Support Partners Include (but not limited to): Global Fund to Fight AIDS, Tuberculosis and Malaria (GF)[2]; the U.S. President’s Malaria Initiative (PMI)[3]; United Kingdom Agency for International Development (UK-AID); World Bank (WB); African Development Bank (ADB); Islamic Development Bank (IDB); The World Health Organization (WHO); United Nations Children’s Fund (UNICEF) Nigeria office[4]; Clinton Health Access Initiative (CHAI); GiveWell Community Foundation (GWCF) and Nigeria Liquefied Natural Gas Company (NLNG).
Figure 1: Vector Control & Malaria treatment progress. 2005-2017
Efforts are however hampered by a number of challenges: population (Nigeria is the most populous country in Africa; it is 7th in the world) – of its ~200 M population 76% are at high risk for Pf malaria – the most dangerous species); high income inequality (the prevalence of malaria parasitemia in rural populations is 2.4 times that in urban populations and malaria prevalence among children in the lowest socioeconomic group is seven times higher than the highest quintile); ongoing security risks (the Boko Haram insurgency, etc); lack of infrastructure to reach into all areas; difficult terrain, weak health systems, etc.
The country is nevertheless making progress concomitant with investments of resources (See figure 1: Vector control and malaria treatment progress in Nigeria 2005-2017. Source: https://www.who.int/malaria/publications/country-profiles/profile_nga_en.pdf?ua=1)
UNICEF is also implementing numerous projects aimed at bringing down the malaria burden such as integrated community case management support and increasing access to rectal artesunate as a pre-referral treatment for severe malaria[5].
Q. Under ‘challenges’ you mentioned the 2019 Ugandan malaria outbreak, (during which RMP Uganda helped increase the supply of transfusion blood in Kamapala) Why did malaria suddenly surge 40% and could it happen in other countries?
Uganda currently hosts more refugees than at any time in its history due to the cycles of violence and instability within the Horn of Africa and Central Africa, with no expected resolution in the near future. This has created a compounded refugee crisis, comprised of a recent refugee influx especially from South Sudan, in addition to a protracted refugee situation, in which a significant number of refugees find themselves in a long-lasting and intractable state of limbo often in refugee settlements. The total refugee population currently stands at nearly 1.5 M being the third highest globally and the highest in Africa.
In Uganda, the Office of the Prime Minister coordinates responses to refugees. Health needs are met through a comprehensive primary healthcare package comprised of clinical and preventive health services delivered at the various levels of the health system by the Ministry of Health, development partners (especially UN agencies and NGO implementing partners) and civil society organizations. The refugee population is included during registration for mass campaigns. These unplanned and unpredictable numbers further constrain the National Health Service delivery and therefore require special considerations. Health services are challenged by the increasing influx of refugees. Integration and quality of services are particularly affected given the high requirements for health care for refugees and the host population. Refugees comprise more than 50% of the population of some host districts, all dependent on available health services further stretching the available health work force.
The 2019 World Malaria Report of 2016 reported that Uganda has the third highest number of annual malaria cases accounting for 5% of the total global cases. Malaria transmission is stable in 95% and unstable in 5% of the country. The Malaria incidence varies from district to district. The transmission peaks are in tandem with the two rainy seasons experienced annually from March to May and September to November. Malaria accounts for 30-50% of outpatient visits, 15-20% of hospital admissions and up to 20% inpatient deaths). Despite this heavy burden, significant progress has been made over the recent past in malaria control due to the substantial investment in malaria control. Prior to COVID, nearly 87% of children with fever had accessed ACTs and 62% of the households had one Long Lasting Insecticide treated Net (LLIN) for every two persons; and 69% of the population slept under LLIN. Parasite Prevalence in children <5-year reduced from 42% in 2009 to 19% in 2014. However, these gains are threatened by the malaria resurgence, especially in Northern Uganda.
Eleven Northern Uganda districts have been battling a protracted malaria resurgence since April 2015. Challenges to containment of this outbreak included limited resources to support social mobilization, procurement of additional stocks of rapid diagnostic tests (RDTs) and artemisinin combination therapy (ACTs), IRS as well as substantial needs for blood transfusion (thank you RMP Uganda for your contribution in Kampala!). The need to support existing National and districts’ efforts to successfully contain and mitigate such resurgences is extremely urgent.
In terms of the whether it could happen in other countries, COVID-19 – especially the containment measures – is perturbing access to essential services[6]. WHO, UNICEF, the Global Fund and many other partners are working assiduously to ensure malaria services are tailored to the context to avoid malaria resurging[7], particularly as modeling shows that the potential malaria outbreak consequences could be extremely lethal particularly in children[8].
Q. Malaria Partners International currently supports numerous Community Health Worker projects in Zambia. Since this is such an effective method for health care delivery, why aren’t more developing countries using this approach?
Actually, many countries are implementing this approach to ensure delivery at the last mile. Even in the times of COVID, WHO and UNICEF are leading proponents of ensuring this key intervention is successful[9]. Some of the challenges impeding extensive uptake of community health services are fiscal policies on volunteerism in a number of countries. UNICEF was a founding member and hosts the Community Health Roadmap initiative [10]which is aimed at helping countries overcome a number of these challenges and ensure that they can successfully institutionalize community health.
Q. Can you explain about cerebral malaria in children and the possible long-term impact of children who survive it?
- Severe malaria is a multisystem, multi-organ disease.
- Children frequently present with a combination of the classical clinical phenotypes: cerebral malaria (CM), severe malarial anaemia (SMA), respiratory distress, and hypoglycaemia.
- Cerebral malaria is defined by WHO as unrousable coma in a patient with P. falciparum parasitaemia.
- Most children with CM regain consciousness within 48 h and seem to make a full neurological recovery.
- However, ~20% die and up to 10% have persistent neurological sequelae. These are particularly associated with protracted or multiple seizures which may cause cognitive deficiency and/or epilepsy.
- Severe malarial anaemia (defined as haemoglobin concentration < 5 g/dl in the presence of falciparumparasitaemia) is more common in children than in adults. The presence of respiratory distress and metabolic acidosis is often (up to 30%) associated with a fatal outcome.
- It is important to remember that there are no clinical features that are pathognomonic for severe malaria. The well-known clinical (fever, impaired consciousness, seizures, vomiting, respiratory distress) and laboratory (severe anaemia, thrombocytopenia, hypoglycaemia, metabolic acidosis, and hyperlactataemia) features of severe falciparum malaria in children, are equally typical for severe sepsis.
- Respiratory distress (deep breathing, Kussmaul’s respiration) is a clinical sign of metabolic acidosis and has emerged as a powerful independent predictor of fatal outcome in falciparum malaria. It can be misinterpreted as cardiac failure and circulatory overload, especially if associated with severe tachycardia.
- In a study on severe malaria conducted in a urban reference Hospital in Bamako, Mali[11], the case fatality rate was 12% in children with CM only as compared to 2% in those with SMA only. Half of the deaths occurred within 12 hours of admission, 92% within 48 hours.
- The most important message to note is that while there are highly effective life-saving medications such as injectable artesunate and artemether, severe malaria is often fatal. The importance of early and precise diagnosis for malaria is vital to 1) ensure that uncomplicated/simple malaria does not progress to severe malaria; 2) that a child with signs of severe disease is taken to a facility where the appropriate treatment for severe malaria can be administered (referral) and 3) where distances or terrain is difficult to get a child to an appropriate referral facility with sufficient time administer pre-referral treatment (RAS) to gain time in administering effective treatment for severe malaria.
Q. What can we do differently to reduce the missed opportunity for ANC attendance and IPTp coverage?
Some of the challenges to increasing ANC attendance include:
- Confusion among health care providers about the IPTp policy
- Weak healthcare systems
- Lack of knowledge among pregnant women
- Financial barriers to accessing antenatal care
What we can do differently to increasing early ANC attendance and concomitant administration of IPTp include (but are not limited to):
- We must sustain robust investment, including national resources, encourage political will, and invest at the community level to support increased knowledge about the need to access ANC early and to ensure IPTp is delivered to every woman who needs it.
- Given how it is usually the most poor women who do not receive IPTp, equity-driven initiative such as social health insurance schemes will help to address the gap.
- Investments in strong supply chains will also support access to a complete ANC package including IPTp with SP.
- Increasing trust in health care workers (human resources for health) would also support increased adherence to early ANC and IPTp through to facility-based delivery.
- Community based social and behavior change which takes into consideration community concerns including social and economic taboos around pregnancy and birth would also help to ensure the success of initiatives aimed at increasing ANC visits and IP
Q. Just wondering what is your thought about Engaging CHWs to identify pregnant women in the community and refer them to attend ANC. Those who are eligible and had not gone for ANC could be given SP dose at the community and referred to ANC for other services. By this way, complement comprehensive ANC services?
Answer: We are all eagerly awaiting the results of the UNITAID financed project[12] on exactly this subject of community-based malaria in pregnancy interventions. In a number of countries, it is already part of a community health workers mandate to check-in on pregnant mothers and after birth their newborns (see Sierra Leone case study here[13])
Q. In the last 2 decades, UNICEF supported and funded MIP, but in recent times I am not sure if the same level of commitment? Is this due to funding level or change in vision focusing more on U5 children?
Answer: Malaria in pregnancy is at an interesting intersection of infectious disease control and sexual-reproductive health. It therefore presents the opportunities and challenges of multi-sectorial entry points and the mandate of various programmes and agencies. While UNICEF’s mandate does specifically target children under 18 and particularly the main killers of children under 5, UNICEF is highly committed to malaria in pregnancy interventions[14] ranging from directed financing through to data analysis to communication for development (UNICEF’s term for SBCC). One of the most visual representations of our commitment was as the host for the “RBM MIP Working group’s call to action on MIP” which is this year celebrating its 5th year anniversary[15].
Q. Why don’t they consider implementing mosquito repellents to refugees, pregnant mothers and children? in case we want to leave no one behind.
Answer:
- Use of topical insect repellent for a child must take into account age, active substance concentration, topical substance tolerance, nature and surface of the skin to protect plus number of daily applications. International recommendations regarding the use of topical repellents in children for the prophylaxis of arthropod borne diseases are limited to short/medium term usage (several weeks). So if the length of expected exposure is over 3 months, other preventive measures are to be preferred.
- Current recommendations include: DEET; Picaridin; Oil of lemon eucalyptus (OLE) or PMD; IR3535
- The American Academy of Pediatrics (AAP) recommends that repellents should contain no more than 30% DEETwhen used on children.
- European guidelines give the following age restrictions for DEET-containing products: should not be used on children less than two years old, and use should be restricted for children between two and twelve years old.
- French recommendations: Newborns and infants < 6 months: avoid all repellent use. Products containing (P)Icaridine should be avoided in children <24 months. Products containing OLE specify that they should not be used on children aged <3 years. Infants 3 to 12 months: only in circumstances of exceptional exposure use DEET (20–30%) not more than once daily. From ages 1 to 12 years, 2 daily DEET applications at the same concentration may be safely used; 12 years old through adulthood: 3 applications daily.
*DEET is not recommended for children with a history of seizures and for pregnant and lactating women, because of its potential neurotoxicity on the fetus and newborn.
Q. I would like to know your strategy on PSM Capacity Building – for staff and local counterparts on Quantification, Forecasting and Tracking of malaria commodities to ensure sufficient stocks and distribution to all the patients who require the commodities.
Answer: Supply Chain Strengthening (SCS) is one of the core pillars upon which UNICEF’s Health System Strengthening approach is based. Health Systems Strengthening consists of an array of initiatives and strategies that improves one or more of the functions of the health system with a view to reaching better health outcomes.
Figure 2: UNICEF support to all areas of supply
Beyond its contribution to reinforcing national health systems, SCS is a fundamental component toward the betterment of public welfare systems and advancement of the SDGs by ensuring populations unhindered access to essential needs and services. To achieve this, SCS aims at:
- Empowering people and institutions through technical guidance and national capacity development to foster government ownership and accountability;
- Engaging public and private sector stakeholders, civil society and development partners to provide a coordinated response to national needs;
- Building the infrastructures and networks required to reach the last mile and foster greater sustainability of care.
UNICEF shares it in-house technical expertise to support countries to build and manage stronger public supply chains -from suppliers to beneficiaries to ensure that all children, adolescent and nursing mothers benefit from unrestricted and continuous access to quality, safe equitable and affordable healthcare and other essential services. To achieve this, UNICEF can lend its technical leadership and expertise to assess national supply chain and identify opportunities for improvement, forecast national needs, match supply chain indicators with health outcomes through data analytics, support domestic resource mobilization efforts and lead institutional and supply chain human resource capacity-development.\
UNICEF lends its technical support and provide guidance to governments in all supply chain areas spanning needs assessments, forecasting, market-influencing, data analytics, resource mobilization, institutional and human resource capacity-development. We identify gaps, guide investments and measure progress.
We leverage high value added cross sector partnerships to build effective supply chain models and sustainably improve equitable access to vaccines, medicines and health technologies. This has enabled governments to provide and lead a coordinated response to national needs, develop quality medicines and vaccines, keep prices affordable, increase in-country logistics capacity and reach the last mile using innovative solutions such as track-and trace for product visibility and drones in hard to reach areas.
Additional Resources:
- UNICEF public supply chain strengthening approach and compendium of tools
- COVID-related guidance on supply chain strengthening
- Leveraging resources
- Contact: UNICEF’s Supply Chain Strengthening Centre (SCSC) strengthening@unicef.org
Q. How great is the problem with other forms of malaria such as vivax or ovale infection?
Answer: The majority of malaria cases are caused by the parasite Plasmodium falciparum, but the number two killer, Plasmodium vivax, has risen in importance in recent years as P. falciparum has come under greater control. It is likely that P. vivax will be much more difficult to eradicate than P. falciparum because of key biological differences between the two species.
Figure 3: P. vivax malaria cases, 2018. Source: WHO Estimates.
Pv accounts for ~50% of clinical episodes outside Africa. A major problem with P. vivax is that most infections are sub-microscopic and asymptomatic. The hypnozoite reservoir which leads to relapses (80-90% of all infections) is also part of the problem and undercuts efforts to eliminate the disease especially as this “liver-stage” infection cannot currently be detected by any diagnostic. In addition while low density reservoirs lead to less infected mosquitoes, as they are very common (the low density infections) they may still contribute significantly to transmission.
Treatment for P.vivax is also complex as only 8-aminoquinolines (primaquine, tafenoquine) are able to eliminate P. vivax hypnozoites from a patients liver and even after >60yrs of using these drugs we still don’t know mode of action and are unsure about the active metabolites. Therefore pregnant women and infants cannot be treated – even though Pv may have its most lethal consequences in these vulnerable groups. These drugs can cause severe haemolytic anaemia in patients with G6PD-deficiency which is why most countries require G6PD testing prior to treatment which cannot be delivered at point-of-care in poor rural communities.
- ovaleis relatively rare compared to Pf and is microscopically very similar to that of P. vivaxand if there are only a small number of parasites seen, it may be impossible to distinguish the two species on morphological grounds alone. The medical treatment for P. ovale and P. vivax is very similar.
COVID-19 has introduced an interesting complication in that Pv in many areas is still chloroquine (CQ) sensitive and indeed is the recommended treatment. Wide-spread CQ use for COVID could compromise elimination efforts by exposing low-density infections and render the parasite resistance thereby reducing the malaria treatment arsenal.
Nevertheless, P. vivax has been eliminated in many countries to-date but efforts must be sustained over a long duration and surveillance strengthened to prevent re-introduction.
Q. What are your thoughts regarding asymptomatic malaria in children and malaria elimination? Should the asymptomatic carriers be left alone?
Answer: Asymptomatic, low-density and Pv/Po infections are the greatest threats to malaria elimination as they can relapse into a full clinical malaria episode, can still transmit malaria, represent a mobile malaria parasite reservoir, are hard to diagnosis and therefore difficult to treat. The highest burden of asymptomatic and low-density infections are primarily in children >5 and therefore have less of the touchpoints (e.g. EPI, wellness checks, etc) to be able to render health services. There nevertheless possible initiatives and innovations to target these reservoirs such as mass-screen and treat and high sensitivity malaria diagnostics.
Q. Should there be screening of all children as a part of routine malaria screening?
Answer: Touch-points to support children’s opportunities to survive and thrive should always be maximized particularly since malaria thrives and exerts its most lethal toll in poor, rural hard-to-reach communities. Where-ever and when-ever there are opportunities to administer confirmatory diagnostics and subsequent effective anti-malarial treatment (e.g. school-based care) is a strong opportunity to accelerate progress towards malaria elimination and improve children’s overall health and well-being.
Q. Currently, Does the UNICEF work with youth in any way? Youth can play a very important role at both advocacy and community level implementation.
Answer: UNICEF is a strong advocate of engagement of young people as change-makers globally and in their communities. Prioritizing the education, protection, health and well-being of children constitutes the best and most robust investment we can make to fulfil the promise of Agenda 2030 – for children, adolescents and youth themselves and the fundamental rights that they have – and for peace, human security and sustainable development for all of us and the planet we inhabit. UNICEF was thus a key proponent of the Addis Ababa Action Agenda (AAAA) which recognizes the link between child- and youth-focused investments and growth by treating children and youth not just as passive recipients of social services and assistance but as active agents of inclusive development. (Source: https://www.unicef.org/sites/default/files/2020-01/HLPF_2020_2PAGER_FINAL_Investing_in_children.pdf)
UNICEF leverages digitial technologies such as U-report to help youth raise their voices and concerns about the key issues affecting them and their opportunities to survive and thrive (e.g. in Liberia[16])
UNICEF has also recently embarked on a new initiative looking at the relatively overlooked area of malaria-infected adolescents, particularly adolescent girls who may become pregnant in malaria-endemic areas.
Other key-youth focused initiatives:
- https://www.unicef.org/world-childrens-day/unicef-youth-ambassadors-and-youth-advocates
- https://www.unicef.org/documents/practical-tips-engaging-adolescents-youth-coronavirus-disease-covid-19-response
- https://www.unicef.org/documents/organizing-youth-activate-talk
For further information/questions please do not hesitate to contact:
Valentina Buj, Global Malaria Advisor, UNICEF/HQ, vbuj@unicef.org
Twitter: #valentinabuj
Information on UNICEF’s actions against malaria: http://www.unicef.org/health/index_malaria.html
[1] https://www.who.int/malaria/publications/atoz/high-impact-response/en/
[2] https://data.theglobalfund.org/investments/location/NGA/Malaria
[3] https://www.pmi.gov/where-we-work/nigeria
[4] https://www.unicef.org/nigeria/sites/unicef.org.nigeria/files/2020-06/UNICEF%20in%20Nigeria%20Brochure.pdf
[5] https://www.swisstph.ch/en/about/med/miru/caramal/
[6] https://www.who.int/publications-detail/10665-332240
[7] https://www.who.int/publications/m/item/tailoring-malaria-interventions-in-the-covid-19-response
[8] https://www.who.int/publications-detail-redirect/the-potential-impact-of-health-service-disruptions-on-the-burden-of-malaria
[9] https://www.unicef.org/media/68811/file/Guidance-Community-based-Health-Care.pdf
[10] https://www.communityhealthroadmap.org/
[11] Source: Ranque S, Poudiougou B, Traor A, Keita M, Oumar AA, Safeukui I, Marquet S, Cabantous S, Diakit M, Mintha D, Ciss MB, Keita MM, Dessein AJ, Doumbo OK. Life-threatening malaria in African children: a prospective study in a mesoendemic urban setting. Pediatr Infect Dis J. 2008 Feb;27(2):130–5.
[12] https://www.tiptopmalaria.org/
[13] https://www.unicef.org/stories/bringing-lifesaving-services-mother-and-baby-rural-sierra-leone
[14] https://data.unicef.org/resources/world-malaria-day-2015-infographic-malaria-pregnancy/
[15] https://endmalaria.org/our-work-working-groups/malaria-pregnancy
[16] https://blogs.unicef.org/blog/changing-young-liberia-through-innovation/