By Dr. Derick Pasternak, Ambassador, Malaria Science & Research Coordinator, MPI 

As we look at the 365-day calendar we see virtually every day dedicated to some cause. The second Sunday in May is Mothers’ Day in the US (different day elsewhere); June 12 the Day Against Child Labor; June 21 International Yoga Day; December 25 is celebrated by Christians the world over as Christmas.  More to the point are February 4, Day Against Cancer; March 24, World TB Day; October 24, World Polio Day and so on.

Why is one day out of 365 meaningful? Should we celebrate that day, like we do in May or on December 25, or use it in our campaigns to right wrongs as people in many countries do on June 12?  The days that are dedicated to the diseases that afflict patients are somewhat different; we recognize the victories (especially against polio) but reaffirm our commitment to deal with the challenges that remain, or especially arise anew.

Malaria is special even among the healthcare dedicated days. While tuberculosis is more deadly (1.1 million deaths; 10.6 million new infections in 2022 [WHO]) the 608,000 deaths among over 240 million new infections are highly concentrated: children under the age of 5 make up over 75% (data from UNICEF).  This is the group that represents the future of any country, deserving of our special attention and efforts.  Pregnant women are also targets of the parasite: it has been suggested that in parts of the world where malaria is endemic, 25% of maternal deaths are due to malaria (Schantz-Dunn & Nour, Rev Obstet Gyn, 2009). World Malaria Day was established by the World Health Assembly following the proposal of the United States in 2007.

The theme of World Malaria Day 2024 is “Health Equity, Gender and Human Rights.” The flagship event in the US is the by now annual Johns Hopkins University sponsored all-day symposium entitled this year “OMICS: Malaria on the Move” which will focus on current research on all aspects of the combat against the disease.  Countries in Africa and Europe join in observance with similar activities.

Where do we stand in our fight against this threat?

“Malaria case incidence reduced from 82.3 per 1000 population at risk in 2000 to 57.2 in 2019, before increasing again to 59.4 in 2020. There was no change in case incidence between 2020 and 2021. Globally, estimated malaria deaths reduced steadily over the period 2000–2019, from 897,000 to 568 000” (WHO). But that are back up to 608,000 in 2022. Among the many challenges we face is to understand why the increase. The COVID-19 pandemic certainly played a role in reducing countries’ ability to sustain anti-malaria campaign, but there seems to be no relief, now that COVID is mostly in the rearview mirror. There are no published current worldwide data yet, but perhaps these examples suffice: The Philippines has seen a 90% increase in cases between 2022 and 2023 (www.pna.gov.ph); in Ethiopia in 2024 “[m]alaria cases have surged to 5.2 million, surpassing 2023 figures and peaking at 705,000 in February alone” (UN OCHA Situation Report March 25, 2024).

Challenges in prevention include the lack of resources. In most of sub-Saharan Africa, where 94% of the world’s malaria sufferers live, community health workers are the backbone of preventive services, including distributing insecticide treated netting, scheduling indoor residual spraying, larval control, and training the population on how to benefit from these activities.  But often the teams are not adequately trained themselves or spread too thin to cover the population for which they are responsible. A similar issue arises with pregnant women not receiving the WHO-recommended preventive regimen of three doses of sulfadoxine-pyrimethamine, partly because of their lack of prenatal care or inadequate training of those providing the care.

Finally, but importantly, prevention may fail because of the development of resistance by the vector mosquitoes, whether by evasion (such as the appearance of Anopheles stephensi in areas of Africa where few or no vectors resided before) or resistance to the insecticide used. While newer insecticides have been deployed in some areas, they are not universally used; their distribution may fail once again because of the already mentioned constraint on resources to buy the new impregnated nets, whether by Government or individuals.

Treatment of malaria is standardized by WHO-endorsed guidelines.  Here also there are many ways in which failure may rear its head. Most dramatic is the development of parasite resistance to artemisinins, which have been the most effective means of treating malaria over the past 15 years. New drug development is ongoing, often drawing on centuries-long use of herbal products by the local populace, just as artemisinins were first produced some 20 years ago after the herbal product’s use for centuries in China.

Perhaps more widespread, at least in much of sub-Saharan Africa, is the inadequate or inappropriate use of the recommended drugs either by choice of patient (or caregiver in the case of children) or poor training of professionals, including once again the community health workers, but also pharmacists, nurses, and physicians.  The professional literature is replete with examples of this inadequacy.

Another challenge must be mentioned. According to the UN, at “the end of June 2023, 110 million people worldwide were forcibly displaced from their homes due to persecution, conflict, violence, human rights violations and events seriously disturbing public order.” These are the refugees. Many of them live in squalid conditions in locations where malaria is endemic. The usual preventive measures may not be effective under these conditions. Attention must be paid to, and effective measures implemented in these domiciliary areas, if this population is to be protected. If that does not happen, they can become a reservoir of infection in their surrounding communities.

As we look at the prospect of further warming of the globe as part of climate change, we can expect the extension of malaria-prone areas in those that are currently deemed malaria free. One or another Anopheles mosquito species lives in these countries.  For example, a recent paper on four Anopheles species in Morocco used modeling to show that they will all acquire new territories under all possible scenarios. This year we have already seen malaria acquired in the US by people who have not traveled out of the country.  Other countries in Africa, Asia, Latin America and Europe may also see domestic recurrence of the disease. It is to be hoped that they have contingency plans for dealing with it. (Hope, of course, is not a plan.)

With these challenges in mind, we can confidently say that indeed there is a good reason for World Malaria Day once a year.  It compels those of us involved and all others interested in the in the fight against malaria to review our current status and plan on effective action to regain the initiative we possessed in the 2010s.

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