Can there be end to malaria scourge?

During this year’s World Malaria Day, last Saturday, the World Health Organisation (WHO) canvassed the need to address gaps in the prevention, diagnosis and treatment of malaria, writes OYEYEMI GBENGA-MUSTAPHA and WALE ADEPOJU. The figures are scary. Malaria,  experts say, kills more people than HIV if appropriate treatment is not given. It is for this that the World Health Organisation (WHO) has called for more commitment to the eradication of the disease in Africa in particular. It made the call during this year’s World Malaria Day last Saturday, with the theme, Invest in the future: Defeat malaria, set by the Roll Back Malaria Partnership. The theme reflects the targets set in a draft post-2015 strategy, to be presented to the World Health Assembly next month. The new strategy aims to reduce malaria cases and deaths by 90 percent by 2030. Four countries have been certified free of malaria in the last decade; they are the United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010) and Armenia (2011). The post-2015 strategy sets the goal of eliminating the disease from a further 35 countries by 2030. The event created a chance to highlight the advances that have been made in malaria prevention and control, and to commit to continued investment and action to accelerate progress against this deadly disease. According to WHO, while huge gains in the fight against malaria have been made in recent years, the disease still has a devastating impact on people’s health and livelihoods around the world, particularly in Africa, where it kills almost half a million children under five each year. According to WHO Assistant Director-General for HIV/AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases, Dr Hiroki Nakatani, effective tools to prevent and treat malaria exist, but more funds are urgently required to make them available to the people who need them and to combat emerging drug and insecticide resistance. “As we celebrate World Malaria Day on April 25, we must recognise the urgent need to expand preventive measures and quality-assured diagnostic testing and treatment to reduce the human suffering caused by malaria,” he said. Head, Malaria Research Programme at the Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, Dr Sam Awolola, said malaria is still a health issue. According to the malariologist, the disease is responsible for most deaths in the country, specifically those in the rural areas where access to tests and modern drugs are often  available. The researcher said most efficient mosquitoes, which transmit malaria parasites, are common in the country because of geographical location. “Malaria is also responsible for lateness or absenteeism from work and low productivity due to loss of man-hour. Malaria is a disease caused by a parasite called plasmodium falciparum carried by anopheles mosquitoes, it is the most virulent. And it is responsible for about 98 per cent cases of malaria,” he said. Awolola said: “There are several species of plasmodium depending on where people are. We have some that even attack animals. But the one that attacks human is called plasmodium falciparum as found in Nigeria, other Africa countries and the Asia. Nigeria; is endemic to malaria because there is a breeding ground for the Anopheles mosquito to thrive. To prevent malaria attack, he recommended, WHO treatment guidelines. Updated “Guidelines for the Treatment of Malaria” as issued by WHO last week. They include the latest recommendations on preventive treatment for infants, children under five and pregnant women. The updated guidelines should help expand access to recommended treatments. For uncomplicated malaria cases, WHO recommends the use of artemisinin-based combination therapies (ACTs). Globally, 392 million ACT courses were procured by malaria-endemic countries in 2013, up from just 11 million in 2005. However, millions of people are still not treated for malaria, primarily because the communities most affected by the disease have limited access to health care. WHO recommends diagnostic testing for all suspected malaria cases to ensure that malaria drugs are used only for those who have the disease and that—when a test is negative—other causes of fever are investigated. Rapid diagnostic tests (RDTs) are now widely available and more than 319 million were purchased in 2013 compared to 46 million in 2008. Despite this progress, nearly 40 percent of people with suspected malaria at public health facilities in Africa are not tested. WHO also recommends that the most vulnerable groups in malaria-endemic areas of sub-Saharan Africa—pregnant women, children under five, and infants—receive preventive treatment to reduce the risk of malaria infection. Preventive treatments are highly cost-effective, with the potential to save tens of thousands of lives each year. Coverage with such treatments, however, remains low and needs to be significantly scaled up. The need to address gaps in preventive treatment for malaria is also being highlighted by the Roll Back Malaria (RBM) Partnership, which has issued a global call to action to increase national coverage with preventive treatment in pregnancy. The malariologist said the best initiative in malaria management is prevention which is better than cure, “and the best method is to sleep under LLINs or get your house treated with indoor residual spray (IRS); they are very effective and should be used according to instructions,” he said. Dr Awolola said Nigerians should embrace the right use of long lasting insecticide treated nets (LLITNs), “insecticide-treated bed nets are the most cost-effective way to prevent its transmission. People should sleep under nets, we found out that many stopped using nets because they claimed they feel too hot underneath but this should not deter them. Our study revealed that people lifestyles could be part of the challenges of not using nets, for instance, the Fulani herd men still sleep in the open air in the north. Nigerians ought to use long lasting insecticide nets, spray the wall of their home with chemicals or use aerosol in the houses. Malaria can be prevented by applying insecticide to the inside walls of individual homes. Mosquitoes that land on treated walls are killed, preventing the transmission of malaria.  Early treatment with anti-malaria drugs, such as Artemisinin-based combination therapies (ACTs) can effectively cure malaria.” Awolola said artemisinim-based combination therapy (ACT) for effective treatment of malaria, according to WHO recommendation should be adopted. He said chloroquine, which was popular in the 80s and 90s as malaria therapy, has failed. This, he said, is because there are parasites that have become resistant to it because of its wrong dosage. “It is still a very effective drug but most people take substandard dosage while some do not follow the required regimen which made the parasites develop resistance to it. This is why we changed from chloroquine and other monotherapies to ACTs. ACT is a combination of two different drugs of two varying modes of action therefore it is very effective against the parasites. In Cambodia and other parts of Asia, they have also resulted to ACTs. That does not mean there is no resistance to ACT. What we try to do at NMIR is to be vigilant. This effort is called pharmacovigilance. We monitor the use of chloroquine in the field, and the parasites with reaction to chloroquine, we’ve researched into how the drug has been effective over the parasites over the years. In whatever we do in the treatment, research or malaria, we stick to WHO recommendations,” he said. He identified a challenge. “Mosquitoes nowadays are adapting to the environment as they are also getting resistant to insecticides. This is becoming a big problem in our environment. At present, it is a key area of research in the country. We are researching into this with the help of WHO, we want to identify why the problem of resistance. We are doing that to support the National Malaria Control Programme (NMCP),” he said. He urged the government to fund malaria more, adding that providing nets or drugs alone cannot solve the problem but rather the environment where mosquitoes breed should be taken care of. “There should be environmental management and protection. Also, there should be re-engineering. The way people build their houses are wrong and it encourages mosquitoes breeding. People should ensure there is environmental sanitation and avoid those practices which encourage mosquitoes, such as putting eaves in houses built, especially in the villages where we have the most burden of the disease and about 60 per cent of the country population,” he said. The researcher said the country is not yet ripe to use vaccine against malaria as the best method is what is presently being done. “Moreover, people should use the prevention prescribed and those having the disease should be promptly diagnosed and receive treatment. They must be tested to be sure they are carrying the parasite before they are given the drug, if not, it will mean they are misusing the drug, which may cause some problems later in life,” he said.