Malaria - safe for now, but for how long?

4 March 2014 – Ten years ago, malaria testing was a job for lab technicians with microscopes, and treatment –mostly the increasingly ineffective chloroquine - was left to professionals.

Today, the field looks very different.

Artemisinin-based combination therapies (ACTs) have replaced chloroquine, proving reliable and effective. Rapid diagnostic tests have brought testing and treatment down to the community level. Many millions of bed nets have been distributed. And elimination of the disease is back on the agenda –  ample funding is now available, from the Global Fund, the President's Malaria Initiative (a US government programme) and the Bill and Melinda Gates Foundation.

“The news is exceptionally good,” Desmond Chavasse, responsible for the malaria and child survival programme at Population Services International, told IRIN News. “We have a one-third reduction in incidence and a halving of malaria child mortality since 2000. In sub-Saharan Africa, about 42 percent of people now have access to treated mosquito nets, so some really fantastic progress there.”

But there has also been one serious change for the worse. ACTs - which have underpinned this success - have stopped working in areas around the Thailand-Cambodia border, an area where drug resistance often first appears. So far, the resistant strains have been contained, but Chavasse warns that the recent successes are “exceptionally fragile”.

“Resistance will get us in the end,” he said, “whether it is insecticide or drug resistance, so we need an elimination goal, and that means we have to do different things, we can't just do more of the same.”

Malaria elimination is a particularly major issue in Cambodia because of the emergence of artemisinin resistance there. The race is on to try to stamp out the resistant strain before it spreads to the rest of the world. Containment will only work in the short term; elimination is the only sure way to preserve drug’s the effectiveness.

But there are many challenges.

Health workers need to log every confirmed case of malaria. In Cambodia, the tracking is being done with a mobile phone app, which is working well, but while this method helps record all cases in public health facilities, health officials cannot be sure they have records of all patients seeking private treatment.

Testing has a revealed a high number of people with very low levels of the parasite in their blood. Do they, too, need to be treated? No one is sure. Perhaps not in Cambodia where the vectors - forest-dwelling mosquitoes - are relatively few. It would be different in Africa, where malaria-carrying mosquitoes are everywhere.

And finally, there is the issue of sustaining efforts. Malaria is already less of a problem in Cambodia than it was, and it is far less of a problem now than dengue fever. This is the moment when enthusiasm can flag, volunteers may lose interest and funding tends to dry up.

“These programmes are not straightforward,” said Simon Brooker of the London School of Hygiene and Tropical Medicine, “And we need to be able to fund them over a long period of time. In fact, it is the last mile which is the most difficult part, and it's very hard to persuade funders to keep on funding a programme when you have nearly eliminated the disease.”

The Consortium's technical director, Sylvia Meek, says the key is good advocacy, especially at the country level, even when the burden of malaria is declining. “There's a real concern,” she said, “that as countries find malaria is much less of a burden than it used to be, and there's a lot of competition for resources, that they won't be able to maintain the intensity of action that is needed for elimination, and they will be winding down just at the time when you need to be winding up.”

Source: IRIN News