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Date: Fri, 19 Sep 2008 15:36:29 -0400
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Subject: Africa: Malaria Control Up; Majority Not Covered


Africa: Malaria Control Up; Majority Not Covered

AfricaFocus Bulletin
Sep 19, 2008 (080919)
(Reposted from sources cited below)

Editor's Note

"Despite big increases in the supply of mosquito nets ...the number
available in 2006 was still far below need in almost all countries.
The procurement of antimalarial medicines through public health
services also increased sharply, but access to treatment,
especially of artemisin-based combination therapy (ACT), was
inadequate in all countries surveyed in 2006. ...  Supplies of
insecticide-treated nets (ITN) ... were sufficient to protect an
estimated 26% of people in 37 African countries. Surveys in 18
African countries found that 34% of households owned an ITN; ...
38% of children with fever were treated with antimalarial drugs,
but only 3% with ACT." - World Malaria Report, 2008

The 2008 World Malaria Report, released this week, documents
substantial advances in the war against malaria. As many as 7
African countries reduced malaria deaths by more than 50% between
2000 and 2006. But there were still almost 900,000 estimated deaths
from malaria in 2006, 91% of them in Africa and 85% of children
under five.

This AfricaFocus Bulletin contains a press release and excerpts
from the summary and key points of the report. The full report and
additional background material is available on the WHO website at
http://www.who.int/malaria/wmr2008/

For previous AfricaFocus Bulletins on health issues, visit
http://www.africafocus.org/healthexp.php

This Bulletin also includes (immediately below) links to two new
featured books in the AfricaFocus Bookshop, one about malaria and
the other the best-selling The House on Sugar Beach, as well as to
an additional selection of books on malaria. Use the links below to
browse or order these books and more from Amazon, Amazon UK, Amazon
Canada or other sources.

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

AfricaFocus Book Notes

The Making of a Tropical Disease: A Short History of Malaria (Johns
Hopkins Biographies of Disease) by Randall M. Packard

Randall Packard's far-ranging narrative traces the natural and
social forces that help malaria spread and make it deadly. He finds
that war, land development, crumbling health systems, and
globalization -- coupled with climate change and changes in the
distribution and flow of water -- create conditions in which
malaria's carrier mosquitoes thrive. The combination of these
forces, Packard contends, makes the tropical regions today a
perfect home for the disease.

Authoritative, fascinating, and eye-opening, this short history of
malaria concludes with policy recommendations for improving control
strategies and saving lives.
More on-line: http://www.africafocus.org/books/isbn.php?0801887127

See more books on malaria at
http://www.africafocus.org/books/themes.php#malaria or
http://www.africafocus.org/books/themes_uk.php#malaria

The House at Sugar Beach by Helene Cooper

A powerfully written personal narrative of Liberia, with historical
insight and journalistic skill. Number 1 Africa best-seller on
Amazon.
More on-line: http://www.africafocus.org/books/isbn.php?0743266242

+++++++++++++++++++++end book notes+++++++++++++++++++++++++++++

Progress made in malaria control, yet burden is enormous

New report finds more funding leading to increased coverage of
malaria control interventions

World Health Organization

Press release

http://www.who.int/mediacentre/news/releases/2008/pr32/en

18 September 2008 | Geneva -- The global burden of malaria remains
enormous, but access to malaria control interventions, especially
bednets in Africa, increased sharply between 2004 and 2006, says a
new report released today.

"With dramatic increases in funding and intense momentum towards
reducing the malaria burden in recent years, we have a greater need
for reliable information and analysis," said WHO Director-General
Dr Margaret Chan. "This report begins to answer that need. Progress
in malaria control has accelerated dramatically since 2006,
especially in the wake of the UN Secretary-General's call for
universal malaria control coverage by the end of 2010. We expect
these expanded efforts to be reflected in future reports."

The World malaria report 2008, which draws upon data collected
between 2004 and 2006, paints a complex picture. Some highlights
are:

* New methods estimate that the number of malaria cases in 2006 was
247 million.

* Small children remain by far the most likely to die of the
disease.

* Malaria deaths have declined in several countries, and a few
African nations have managed to reduce deaths in half by following
the recommended measures.

* As of 2006, more funding resulted in accelerated access to
malaria interventions, including bednets and effective medicines.

* In Africa, the artemisinin-based combination therapy (ACT), which
is recommended by WHO, reached only 3% of children in need.

Bednet coverage increasing

The report finds that recent increases in malaria funding were
beginning to translate into coverage of key malaria interventions,
especially bednets, by 2006. The percentage of children protected
by insecticide-treated nets increased almost eightfold, from 3% in
2001 to 23% in the 18 African countries where surveys were held in
2006. Procurement of antimalarial medicines also increased sharply
between 2001 and 2006. About 100 million people, including 22
million in Africa, were protected by indoor spraying of
insecticide.

However, much more work remains to be done. In Africa, only 125
million people were protected by bednets in 2007, while 650 million
are at risk.

"Malaria is a primary cause of child mortality," said Ann M.
Veneman, Executive Director of the United Nations Children's Fund
(UNICEF). "If the availability of bednets and other key
interventions can be increased, lives can be saved."

Positive impact

For the first time, three African countries reported dramatic
reductions in malaria deaths by 50% or more. Eritrea, Rwanda and
Sao Tome and Principe achieved this result between 2000 and
2006/2007 through a mix of bednet distribution, indoor spraying,
improved access to treatment and advances in disease surveillance.
Furthermore, significant improvements were observed in other
African countries such as Madagascar, Zambia and the United
Republic of Tanzania.

Six more countries reported a fall in malaria deaths by 2006:
Cambodia, the Lao People's Democratic Republic, the Philippines,
Suriname, Thailand and Viet Nam.

"We know that malaria control interventions work and that we can
make rapid progress towards ending malaria deaths," said Ray
Chambers, the United Nations Secretary-General's Special Envoy for
Malaria. "Now is the time to expand these results to all of Africa
and the rest of the world."

According to data from national malaria control programmes, Africa
had a larger increase in funding than any other region between 2004
and 2006. The investments were led by the Global Fund to Fight
AIDS, Tuberculosis and Malaria, and supported by bilateral and
multilateral organizations and national governments.

In other regions, sources of funding were highly variable, but
national governments provided the bulk of monies. While funding for
malaria was higher than ever before in 2006, it is not yet possible
to judge which countries have adequate resources and there are
still significant gaps.

For more information please contact:

Dick Thompson, News Team Leader, WHO, Geneva

Telephone: +41 22 791 1492, Mobile: +41 79 475 5534, E-mail:
[log in to unmask]

Fadela Chaib

Telephone: +41 22 791 3228, Mobile: +41 79 475 5556, E-mail:
[log in to unmask]

*************************************************************

World Malaria Report 2008

World Health Organization

[Excerpts only, from summary and key  points. Full report and other
background material available at
  http://www.who.int/malaria/wmr2008/]

Summary

There were an estimated 247 million malaria cases among 3.3 billion
people at risk in 2006, causing nearly a million deaths, mostly of
children under 5 years. 109 countries were endemic for malaria in
2008, 45 within the WHO African region.

The combination of tools and methods to combat malaria now includes
long-lasting insecticidal nets (LLIN) and artemisinin-based
combination therapy (ACT), supported by indoor residual spraying of
insecticide (IRS) and intermittent preventive treatment in
pregnancy (IPT). Despite big increases in the supply of mosquito
nets, especially of LLIN in Africa, the number available in 2006
was still far below need in almost all countries. The procurement
of antimalarial medicines through public health services also
increased sharply, but access to treatment, especially of ACT, was
inadequate in all countries surveyed in 2006.

Household surveys and data from national malaria control programmes
(NMCPs) show that the coverage of all interventions in 2006 was far
lower in most African countries than the 80% target set by the
World Health Assembly. Supplies of insecticide-treated nets (ITN)
to NMCPs were sufficient to protect an estimated 26% of people in
37 African countries. Surveys in 18 African countries found that
34% of households owned an ITN; 23% of children and 27% of pregnant
women slept under an ITN; 38% of children with fever were treated
with antimalarial drugs, but only 3% with ACT; and 18% of women
used IPT in pregnancy. Only 5 African countries reported IRS
coverage sufficient to protect at least 70% of people at risk of
malaria.

In regions other than Africa, intervention coverage is difficult to
measure because household surveys are uncommon, preventive methods
usually target high-risk populations of unknown size, and NMCPs do
not report on diagnosis and treatment in the private sector.

While the link between interventions and their impact is not always
clear, at least 7 of 45 African countries/areas with relatively
small populations, good surveillance and high intervention coverage
reduced malaria cases and deaths by 50% or more between 2000 and
2006 or 2007. In a further 22 countries in other regions of the
world, malaria cases fell by 50% or more over the period 2000 2006.
However, deeper investigations of impact are needed to confirm that
these 29 countries are on course to meet targets for reducing the
malaria burden by 2010.

Key points

Background and context

A renewed effort to control malaria worldwide, moving towards
elimination in some countries, is founded on the latest generation
of effective tools and methods for prevention and cure.

1. The advent of long-lasting insecticidal nets (LLINs) and
artemisinin-based combination therapy (ACT), plus a revival of
support for indoor residual spraying of insecticide (IRS), presents
a new opportunity for large-scale malaria control.

2. To accelerate progress in malaria control, the 2005 World Health
Assembly (WHA) set targets of >= 80% coverage for four key
interventions: insecticide-treated nets for people at risk;
appropriate antimalarial drugs for patients with probable or
confirmed malaria; indoor residual spraying of insecticide for
households at risk; and intermittent preventive treatment in
pregnancy. The WHA further specified that, as a result of these
interventions, malaria cases and deaths per capita should be
reduced by >= 50% between 2000 and 2010, and by >= 75% between 2005
and 2015.

3. The World malaria report 2008 uses data from routine
surveillance (~ 100 endemic countries) and household surveys (~ 25
countries, mainly in Africa) to measure achievements up to 2006
and, for some aspects of malaria control, to 2007 and 2008. In five
main chapters, 30 country profiles and seven annexes, the report
describes: (a) the estimated burden of disease in each of the 109
countries and territories with malaria in 2006; (b) how
WHO-recommended policies and strategies on malaria control have
been adopted, by country, region and globally; (c) the progress
made in implementing control measures; (d) the sources of funding
for malaria control; and (e) recent evidence that interventions can
reduce cases and deaths.

Burden of malaria in 2006, by country, region and globally

Half of the world's population is at risk of malaria, and an
estimated 250 million cases led to nearly 1 million deaths in 2006.

4. An estimated 3.3 billion people were at risk of malaria in 2006.
Of this total, 2.1 billion were at low risk (< 1 reported case per
1000 population), 97% of whom were living in regions other than
Africa. The 1.2 billion at high risk (>= 1 case per 1000
population) were living mostly in the WHO African (49%) and South-
East Asia regions (37%).

5. There were an estimated 247 million episodes of malaria in 2006,
with a wide uncertainty interval (5th-95th centiles) from 189
million to 327 million cases. Eighty-six percent, or 212 million
(152-287 million) cases, were in the African Region. Eighty percent
of the cases in Africa were in 13 countries, and over half were in
Nigeria, Democratic Republic of the Congo, Ethiopia, United
Republic of Tanzania and Kenya. Among the cases that occurred
outside the African Region, 80% were in India, Sudan, Myanmar,
Bangladesh, Indonesia, Papua New Guinea and Pakistan.

6. There were an estimated 881,000 (610,000-1,212,000) malaria
deaths in 2006, of which 91% (801,000, range 520,000-1,126,000)
were in Africa and 85% were of children under 5 years of age.

...

Policies and strategies for malaria control

National malaria control programmes have adopted many of the
WHO-recommended policies on prevention and cure, but with variation
among countries and regions.

8. Nearly all of the 45 countries in the African Region had
adopted, by the end of 2006, the policy of providing insecticidal
nets free of charge to children and pregnant women, but only 16
aimed to cover all age groups at risk. ITNs are also used in a high
proportion of countries in the South-East Asia and Western Pacific
regions, but in relatively few countries in the other three WHO
regions.

9. Indoor residual spraying is generally used in foci of high
malaria transmission. IRS is the dominant method of vector control
in the European Region. It is used in fewer countries in Africa,
the Americas and South-East Asia, and least in the Western Pacific
Region.

10. By June 2008, all except four countries and territories
worldwide had adopted ACT as the first-line treatment for P.
falciparum. Free treatment with ACT was available in 8 of 10
countries in the South-East Asia Region, but a smaller proportion
of countries in other regions.

11. The systematic use of intermittent preventive treatment in
pregnancy is restricted to the African Region; 33 of the 45 African
countries had adopted IPT as national policy by the end of 2006.

Preventing malaria

Despite big increases in the supply of mosquito nets, especially of
long-lasting insecticidal nets in Africa, the number available is
still far below need in most countries.

12. Between 2004 and 2006, there were modest increases in the
supply of conventional ITNs to countries in the African, South-East
Asia and Western Pacific regions, the three regions where nets are
most frequently used. By contrast, there was a large increase in
the supply of LLINs to countries in the African Region, reaching 36
million in 2006.

13. Based on NMCP records of ITN supplies, however, only six
countries in the African Region had sufficient nets (ITNs including
LLINs) by 2006 to cover at least 50% of people at risk. These were
Ethiopia, Kenya, Madagascar, Niger, Sao Tome and Principe, and
Zambia. ITN supplies were sufficient to protect 26% of people in 37
African countries that reported in 2006.

...

16. Indoor residual spraying (IRS) is used focally in all regions
of the world. In the African Region, NMCP data indicate that more
than 70% of households at any risk of malaria were covered in
Botswana, Namibia, Sao Tome and Principe, South Africa and
Swaziland. In other regions of the world, relatively high coverage
(> 20% of people at risk) was achieved only in Bhutan and Suriname.

Treating malaria

The procurement of antimalarial medicines through public health
services increased sharply between 2001 and 2006, but access to
treatment, especially of artemisinin-based combination therapy, was
inadequate in all countries surveyed in 2006.

17. Between 2001 and 2006, NMCPs reported large increases in the
number of courses of antimalarial drugs supplied through public
health services. In particular, doses of ACT increased from 6
million in 2005 to 49 million in 2006, of which 45 million were for
African countries. These NMCP figures probably underestimate usage,
and the exact consumption of ACT is not known.

18. According to NMCP data, only 16 million rapid diagnostic tests
(RDT) were delivered in 2006, of which 11 million were for
countries in Africa, a small quantity in comparison with the number
of malaria episodes.

...

20. According to national household surveys, however, none of the
populations of 18 African countries surveyed in 2006 and 2007 had
adequate access to antimalarial drugs. Only in Benin, Cameroon,
Central African Republic, Gambia, Ghana, Uganda and Zambia were
more than 50% of all children with fever treated with an
antimalarial drug. In no country did access to treatment reach the
80% target, and the average across the 18 countries was 38%. The
use of ACT was much lower: just 3% of children on average, ranging
from 0.1% in Gambia to 13% in Zambia.

...

Financing malaria control

Funding for malaria control in 2006 was reported to be greater than
ever before, but it is not yet possible to judge from NMCP budgets
which countries have adequate resources for malaria control.

23. According to NMCP data for 2006, the African Region had more
funds for malaria control than any other, and reported a larger
increase in funding than any other region between 2004 and 2006.
However, the total of US$ 688 million for the African Region in
2006 is certain to be an underestimate because reports were
submitted by only 26 of 45 countries. The US$ 4.6 available per
(estimated) malaria case in the 26 reporting countries is unlikely
to be adequate to meet targets for prevention and cure.

24. The major sources of extra funds for African countries between
2004 and 2006 were reported to be the national governments of the
affected countries plus the Global Fund to Fight AIDS, Tuberculosis
and Malaria. These two sources dominated funding for malaria
control in the African Region and worldwide in 2006.

...

Impact of malaria control

Some countries that have implemented aggressive programmes of
prevention and treatment, in Africa and other regions, have
reported significant reductions in the malaria burden.

...

27. Among 41 African countries that provided case and death reports
over the period 1997-2006, the most persuasive evidence for impact
comes from four countries, or parts of countries, with relatively
small populations, good surveillance, and high intervention
coverage. They are Eritrea, Rwanda, Sao Tome and Principe, and
Zanzibar (United Republic of Tanzania). All four countries/areas
reduced the malaria burden by 50% or more between 2000 and 2006
2007, in line with WHA targets.

28. In other African countries where a high proportion of people
have access to antimalarial drugs or insecticidal nets, such as
Ethiopia, Gambia, Kenya, Mali, Niger and Togo, routine surveillance
data do not yet show, unequivocally, the expected reductions in
morbidity and mortality. Either the data are incomplete, or the
effects of interventions are small.

29. The reportedly high coverage of indoor residual spraying in
Namibia, South Africa and Swaziland is consistent with the observed
declines in case numbers in these countries, and evidently builds
on earlier successes achieved with IRS.

...

*************************************************************
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.

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