Breaking the cycle of malaria and death in emergencies: the way forward

Malaria kills more than a million people each year. Nearly one out of every three of these deaths occurs in an emergency setting – within populations displaced by violence, struggling to get the food, water, shelter and security they need to live, and with unpredictable access to public health services. In these conditions, vulnerability to malaria increases because people are more likely to be bitten by mosquitoes, are often ill with other infections and lack access to health care. When a humanitarian crisis occurs in a malaria-prone area, malaria deaths may exceed those resulting from other more immediate causes – unless proper control measures are adopted.

The context

Malaria was endemic all over the world until just half a century ago. Although it has been eradicated in the industrialised countries of the northern hemisphere and Australia, it still threatens 40% of the world’s people, mostly those living in the poorest countries. The toll of malaria began to worsen in the 1990s, when the medicines used to treat it lost their effectiveness because of parasite resistance.

It is estimated that there are between 350 and 500 million episodes of malarial illness across the world each year. Over 80% of malaria deaths occur in Sub-Saharan Africa, and most of these deaths are among infants or very young children. Malaria kills more African children under five than any other single infection, and is a major cause of low birth weight and anaemia. If children survive malaria, they may suffer from brain damage or paralysis. Pregnant women are also especially vulnerable.

Malaria keeps poor people poor. In Africa alone, the total economic burden of malaria is estimated at $12 billion annually. Households threatened by malaria spend up to a quarter of their income on medical consultations, mosquito-treated nets, medicines, laboratory tests and funerals for victims. They are less productive and lose income because of absences from work or inability to plant and harvest crops. Children lose out on educational opportunities. Malaria control has been identified as one of the four most cost-effective means to fight poverty, and controlling malaria will make a vital contribution to fulfilling the Millennium Development Goals.

In poor countries, proper malaria control is a daunting task, even under stable conditions. The pattern of disease is affected by meteorological changes or environmental shifts: both can cause an upswing in malaria incidence, adding to the stress faced by health services. Rainfall and temperature-related epidemics in African highland areas, for example, may result in illness affecting up to 50% of the population. Local health services are overwhelmed. When millions of people are affected by such an epidemic, the result in suffering and death represents a humanitarian crisis in its own right. In Ethiopia, a malaria epidemic in 2003 is estimated to have affected 21.9 million people in 38 zones, resulting in (at a conservative estimate) 8.7 million cases, with 263,000 deaths (see pp. 00–00 of this issue).

Complex emergencies created by war or civil unrest undermine efforts to improve malaria control. In 1984, when Burundi was politically stable, the number of malaria cases each year was 200,000. In 2000, following a period of internal violence and instability, reported annual malaria cases in Burundi were over 3 million. In the late 1970s, the authorities in Afghanistan reported around 300,000 malaria cases annually. By the 1990s, this had risen to 2–3 million cases a year – one of the highest malaria burdens outside Africa. Twenty per cent of confirmed cases in Afghanistan are falciparum malaria (the lethal form of the disease), and falciparum malaria has crossed the northern border into Tajikistan. A survey by the International Rescue Committee in the eastern Democratic Republic of Congo (DRC) during 2000 showed that, during a period when violent deaths increased over five-fold, malaria-specific mortality more than tripled.

Treatment strategies

In response to the growing crisis, several new initiatives have been launched to reduce the burden of the disease. One – Roll Back Malaria (RBM) – was started by the World Health Organization (WHO) in 1998. It now functions as a global partnership, committed to halving the burden of malaria by 2010. WHO provides technical support to RBM partners.

The importance of tackling malaria in emergencies has also come more sharply into focus, and over the past five years strategies for controlling malaria in emergencies have been refined. There is a clearer understanding of how tasks should be allocated between different partners. A Malaria in Emergencies Network, facilitated by WHO and open to all major partners and implementing agencies, holds regular teleconferences for strategic planning, and operates an email listserv that ensures that vital information can be shared with all concerned whenever an emergency strikes.

WHO’s fundamental strategies for addressing falciparum malaria in emergencies are:

• Provide universal access to prompt diagnosis and treatment with artemisinin-based combination therapy (ACT), the most effective antimalarial medicines available today (see pp. 00–00 of this issue).
• Organise outreach services for isolated populations and vulnerable groups. Emergency personnel must get good, routine intelligence about the status of all populations affected by the emergency, and seek out those who are ill, going out on the equivalent of hospital rounds
• Set up a surveillance/early-warning system to detect outbreaks of malaria and other important causes of disease at the earliest possible stage
• Preparedness: have trained personnel and supplies readily available.
• Respond swiftly to intelligence about any potential malaria outbreak (clustering of severe malaria cases and deaths, or a sharp rise in reported fever cases) by investigating extents and possible causes, and intervene rapidly if an epidemic is confirmed
• Engage in community prevention campaigns through distribution of insecticide-treated mosquito nets (ITNs: see pp. 00–00 of this issue) and education about how to use them, or indoor residual spraying (IRS) with insecticides once local conditions permit high population coverage (80% for ITN, and above 85% for IRS).
• Ensure that health services and all the measures needed to save lives are provided free of charge to the user, for as long as the emergency conditions last.

National and international humanitarian organisations, national authorities and community groups understand the extraordinary burden imposed by malaria during crises. To break the cycle of malaria infection, sickness and death they need funds, supplies and expertise. The financial position has improved in recovering situations as money has become available through the Global Fund to Fight TB, AIDS and Malaria (GFTAM), a partnership between governments, civil society, the private sector and affected communities. The Fund was created to increase resources to fight three of the world’s most devastating diseases, and to direct those resources to areas of greatest need. A total of $133 million has been pledged to Angola, Burundi, the Central African Republic, the DRC, Haiti, Liberia, Somalia and Sudan, of which almost $53 million has been disbursed. However, programme management is a difficulty, and crisis-affected countries will face challenges in absorbing funds allocated to them.

Impacts

The impact of the new strategies is not yet established. However, evidence from disease surveillance programmes suggests that their consistent application will substantially reduce malaria deaths. There are suggestions that this was the case during the recent crisis in Darfur. During 2004, local authorities, NGOs and UN agencies undertook malaria control activities with a view to reducing the malaria risks experienced by displaced people in Darfur. These measures included:

• spraying of all temporary shelters in the major camps with residual insecticide (reaching at least 85% coverage, the threshold for community-wide protection
• implementation of an agreed strategy for providing insecticide-treated mosquito nets;
• routine home visits in the camps to detect people with febrile illnesses, and treat them
• widespread use of rapid diagnostic tests;
• fast-track adoption of the government’s new policy for malaria treatment with ACT; and
• weekly surveillance, relying on an agreed set of indicators, for correct reporting of malaria cases and providing feedback – including warnings about sudden upsurges – to all partners.

The rains in Darfur in 2004 were lighter than normal, and this helped reduce the risk of widespread epidemic malaria during the crisis. Malaria control measures in camps and villages prevented the clustering of severe malaria cases and deaths. The death rate from malaria (the case fatality rate), measured at health facilities, was low (0.2%), implying that those who did seek help received prompt and effective care.

The Darfur results imply that, even in adverse conditions, and where humanitarian access is constrained, effective malaria control measures can be implemented provided that field-based agencies work together effectively, under the leadership of a competent authority (in this case WHO, together with the national malaria control programme).

Malaria control proposals should be supported only if they reflect evidence-based strategies. Plans for malaria control in rapidly changing contexts, such as crises and complex emergencies, should include regular reviews of activities, either implemented or planned. This should increase the likelihood that control strategies match needs, and are not made unduly rigid by funding agreements.

In complex emergencies, where data on the parasite susceptibility to different treatment regimes are rarely available, ACT is the treatment of choice, and in each crisis a standard policy of ACT-based medication is essential. The Darfur experience showed the feasibility of using ACT for the treatment of falciparum malaria in a crisis setting, and the importance of providing this therapy free of charge to those who need it. Several studies have shown that cost-sharing discourages people in crises from seeking care. Work by Médecins sans Frontières during the Burundi crisis in 2003 and 2004 showed an association between the cost to patients for malaria treatment and the number of deaths due to malaria. A three- to five-fold increase in fees was associated with a doubling of fatalities attributed to malaria.

Coordinated and well-financed action results in effective malaria control and reductions in malaria deaths in humanitarian crises and emergencies. Both national and international bodies with the expertise to provide strategic coordination for malaria control need consistent financial backing so that they can deploy experienced people to settings characterised by crisis and emergency.

Dr Fatoumata Nafo-Traoré is the Director of the Roll Back Malaria Department in the World Health Organisation. His email address is nafof@who.int. Dr David Nabarro is Representative of the Director-General for Health Action in Crises, WHO. His email address is nabarrod@who.int.