ECHO the European Commission Directorate-General for Humanitarian Aid funds relief operations for victims of natural disasters and conflicts outside the European Union. Aid is channelled impartially, straight to victims, regardless of their race, religion or political beliefs. Resources are not limitless and priorities are given to acute needs, with a particular focus on situations where mortality is high, sudden and greater than usual trends. A frequently used term to describe this above-average mortality is excess mortality. A proper needs assessment is therefore a key element to initiate dialogue between ECHO and a partner seeking funding for a project. ECHO is a donor, not a technical body. Partners are therefore expected to have the necessary technical competence to ensure that they are working in line with best practices in the field. Nevertheless, a partners experience and competencies vary enormously. ECHO medical experts collect the experience generated in funded projects to describe the evolution of practice and trends in those projects.
In West Africa, malaria prevention, diagnosis and treatment is not funded as a stand-alone activity, but as an element of a larger health project. Malaria epidemics can be an exception to this general trend. During an acute emergency, with high crude mortality rates and high under-five mortality rates, malaria is frequently a leading cause of death. Providing adequate diagnosis and access to effective treatment reduces mortality. The proportion of suspected malaria cases in a typical ECHO-funded health project in West Africa is between 20% and 35% of all consultations, depending on the season and the area. During the last 23 years, many questions have arisen regarding the treatment protocol for malaria in West Africa. High resistance has developed to chloroquine and to sulfadoxine-pyrimethamine in most of Africa. In June 2004, 11 of the 17 countries covered by the ECHO regional office for West Africa had chloroquine as their first-line treatment in the national protocol, and four had first-line Artemisinin combinations. By June 2005 the situation had reversed: chloroquine was still officially the first-line treatment for five countries, while 11 officially had Artemisinin-based combinations as first-line treatment. Not all 11 have implemented the change in practice, however.
Mortality due to malaria is more effectively reduced by using a treatment to which there is no or little resistance, among which Artemisinin Combination Therapy (ACT) is the recommended option. Studies in Senegal point to a two- to 11-fold increase in mortality after resistance appeared.4 The important difference in cost between chloroquine and ACT should be highlighted as an obstacle to the rapid and generalised introduction of ACT. ECHO faces some difficult questions regarding the funding of malaria treatment in West Africa. What should be done when partners proposals include ACT, but ACT is not part of the national protocol? What should be done with proposals that still include chloroquine in accordance with a national protocol, when resistance to chloroquine is known to be high? If, as an exception authorised by the ministry of health, a certain area and population is covered with ACT for a limited time, what are the consequences and the possibilities for the future? In eastern Chad, for example, ACT is allowed as an exception due to the excess mortality linked with the arrival of refugees from Darfur. These questions have been partially answered in practice by the drastic evolution in the national protocols in the last 12 months, as described above.
Malaria should always be treated with an effective treatment protocol. Targeting the most vulnerable populations will effectively reduce mortality. Among vulnerable populations, children under two years of age and pregnant women are an absolute priority. Children under five, malnourished children and children with HIV are also a priority. Pregnant women should receive Intermittent Presumptive Therapy (ITP)5 if this is part of the national protocol.
ECHOs current practice
ECHO is open to providing the additional cost of ACT as first-line treatment because it is often the case in ECHOfunded programmes that the first contact with the malaria patient will be the only contact, and a first-line non-ACT treatment is not as effective in reducing mortality. Combined tablets or co-formulated blister packs are the preferred options for ACT, as they facilitate the intake of two different combined medicines and increase compliance. Using ACT rather than chloroquine increases the cost per treatment by at least one euro, depending on the combination chosen and the type of diagnostic confirmation used. For example, a 2001 project that performed 100,000 consultations a year, 30% of which were chloroquine-treated suspected malaria, cost 1,100,000 euros. The same project using ACT, RDT and targeted impregnated mosquito net distribution would cost around 1,155,000 euros today (a 5% increase).
Situations with acute excess mortality require diagnosis and treatment to be not only adequate, but also accessible. ECHO partners are advised to make malaria treatment available at no cost in West Africa when ECHO funds have been provided. Partners could also choose to ask for a fee; in that case, there are specific rules for cost recovery in ECHO-funded projects, and the effect of the fee on accessibility to treatment should be analysed. In cases of acute excess mortality, there should be no economic barrier to appropriate diagnosis and treatment in ECHO-funded projects.
The most challenging scenario from a managerial point of view is also the most common in West Africa: the national protocol is changing, but the shift in the field has not yet begun, or is just starting. Training, procurement and strategies for the introduction of protocol changes and many other elements have to be dealt with in order to prevent bottlenecks to implementing the change. The increasing demand for ACT is straining production capacity, and this could cause shortages of medicine. There is also a greater risk of finding counterfeit drugs. Procurement and quality assurance are therefore important elements of a proposal.
Appropriate treatment is also dependant on appropriate diagnosis. Up to 500 million people are diagnosed with malaria every year, many of them only on the basis of clinical signs which can be as unspecific as fever. It is estimated that, in up to half of suspected cases, fever may in fact not be due to malaria but to other causes. Malaria diagnosis with available laboratory tests (i.e. microscopy or rapid diagnostic tests (RDT)) increase confidence in the treatment and reduce the risks of prompt resistance through misuse of the treatment. Negative diagnostic results encourage us to search further for other causes of the symptoms. Microscopic diagnosis is cheaper and more sustainable. RDTs are to be considered as an emergency or intermediate measure when microscopy is not available, or when the burden of tests makes microscopy a hindrance to timely treatment. A combination of RDTs for small children and pregnant women and microscopy for the rest is an option. RDT may be the only way to confirm malaria in pregnant women when malaria parasites are sequestrated in the placenta. Despite stressing the need for appropriate diagnosis, there are situations where laboratory confirmation is not required; this may be the case in malaria epidemics. Confirmation may not be a requirement for children under five years in high-transmission areas. It is nevertheless imperative to look for alternative causes of fever in each child.
ECHO-funded projects prioritise treatment over prevention. Programmes that include both treatment and prevention spend around one euro on prevention for every four euros spent on treatment. When prevention is included in a proposal, the prevention elements focus particularly on pregnant women, children under two years of age and severely malnourished children. Preventive activities in emergency settings include impregnated mosquito nets if the population is already familiar with their use, with a preference for long-lasting nets; indoor residual spraying has sometimes been supported when expected coverage is higher than 80% and the malaria season is imminent (but has not yet started), and the shelter material allows for indoor retention of the insecticide. ECHO has also funded trials of insecticide-impregnated plastic sheeting.
In conclusion, whenever possible ECHO is funding evidencebased, effective approaches to reducing malaria mortality and morbidity, mostly within the framework of a larger health emergency project. In general, ECHO is supporting the shift from traditional, less effective protocols to ACT protocols where a high resistance to the medicines used is proven or suspected.
Jorge Castilla is West Africa Medical Coordinator for ECHO. His email address is firstname.lastname@example.org. The views and opinions expressed in this article are those of the author. They do not necessarily state or reflect the views and opinions of ECHO, and may not be attributed to ECHO. The content of this article is practice-oriented, and based on the observed evolution in approaches to malaria in ECHO-funded projects.