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Malaria continues to affect communities and threaten lives in Africa, the region that suffers the most burden of the disease. The second webinar of the End Malaria series hosted by AFIDEP’s Platform for Dialogue and Action on Health Technologies in Africa (Health Tech Platform) focused on the threats faced by the region in its quest to eliminate the disease, shedding light on the path ahead and the urgent need for collective action.

Over the past few decades, remarkable strides have been made to end Africa’s malaria burden. Frontline tools, including insecticide-treated bed nets (ITNs) and artemisinin-based combination therapies (ACTs), have played significant roles in saving countless lives and curbing the spread of the disease over the past two decades. Between 2000 and 2021, over 11 million deaths and two billion cases of malaria were averted, mostly in the African region, through concerted efforts and the implementation of these frontline tools.

However, the resistance of both the vector and parasite to insecticides and drugs, respectively, is among several threats impeding the achievement of the global goal of a 90% reduction in malaria incidence and deaths by 2030, as noted by Mr Balla Jatta, Neglected Tropical Diseases Programme Manager, Epidemiological and Disease Control Unit at the Ministry of Health-The Gambia in his keynote address. Other threats he highlighted include the effects of climate change and invasive species; pressure on health systems; and rural-urban migration, which contributes to the introduction of malaria in low-transmission urban areas.

The declining effectiveness of current tools for malaria control

This growing resistance to insecticides and drugs is contributing to the declining effectiveness of ITNs and ACTs, and consequently, countries are 48% off track to eliminating malaria by 2030, according to WHO figures. This statistic was highlighted by Dr Michael Okal, Director of Research and Development at Vector Health International Ltd, as he delved into mosquito and parasite facets of resistance and their implications for elimination efforts.

The primary strategy for vector control involves the use of ITNs and indoor residual spraying. These interventions aim to weaken and eliminate mosquitoes when they come into contact with insecticides. However, with the growing resistance, mosquitoes can now survive exposure to these insecticides, allowing them to continue transmitting malaria. On the other hand, the standard treatment for malaria ACTs, involves a combination of drugs to ensure the complete clearance of parasites from the infected individual. Growing Plasmodium parasite resistance to the effects of drugs used for treatment is leading to treatment failures, necessitating the discovery and development of new chemotherapeutic agents.

The challenge towards meeting the global goal in Africa has been compounded by the invasion of the resistant mosquito species, Anopheles stephensi, which is native to Asia. While speaking on lessons from India on controlling the species, Professor Arti Prasad, Professor and Head of the Department of Zoology at Mohanlal Sukhadia University, noted that key to India’s elimination strategy is a robust case-based surveillance system and early diagnosis and complete treatment. Case-based surveillance involves actively monitoring and tracking malaria cases at the community level and responding promptly to prevent further transmission. Further, the elimination strategy emphasises the importance of accurate and timely diagnosis to ensure that individuals infected with malaria receive appropriate treatment promptly. Early diagnosis and treatment interrupt disease transmission, contributing to its elimination.

Confronting the climate change threats to malaria control

The impact of climate change amplifies the threat of malaria in Africa. Rising temperatures create favourable conditions for the increase in malaria-carrying mosquitoes. These insects thrive in warm environments, and as temperatures increase, their reproduction rates accelerate. Extended seasons of warmth prolong the breeding period, allowing mosquitoes to multiply rapidly, leading to a surge in malaria transmission. Additionally, higher temperatures accelerate the development of the malaria parasite within mosquitoes. This results in the expanded geographic range of malaria, and regions that were once considered low-risk are now more susceptible.

Further, altered rainfall patterns resulting from climate change contribute to increased mosquito breeding sites. Areas experiencing increased rainfall may witness the creation of stagnant water bodies, which serve as breeding grounds for mosquitoes. Conversely, areas affected by prolonged droughts may see a decline in mosquito populations. However, when rain falls after a drought, the sudden availability of water can trigger a rapid increase in mosquito populations, leading to malaria outbreaks. These unpredictable shifts in rainfall patterns disrupt traditional malaria control measures, necessitating adaptive strategies to mitigate the disease’s impact.

Dr James Chirombo, Biostatistician at the Malawi Liverpool Wellcome Programme, argued that it is important for countries to understand local climate patterns and variations, as well as the aftermath of extreme weather events and incorporate climate data in malaria control and elimination efforts. Other adaptation strategies, such as early warning systems and climate-resilient infrastructure, must be prioritised alongside global efforts to address climate change.

Strengthening health systems, a key priority

Effective malaria interventions are dependent on strong health systems. The burden of malaria weighs heavily on Africa’s fragile healthcare systems. Limited access to quality healthcare services, inadequate infrastructure, and insufficient human resources derail timely malaria diagnosis, treatment, and surveillance efforts.

As Dr Chris Barasa, Chief of Party at Amref Health in Kenya, noted, African countries must streamline public health functions, especially primary healthcare, to build resilience in efforts to improve, promote, protect and restore the health of all people. Resilience, in this context, refers to the capacity of actors, health institutions, and populations to prepare for, respond to, and recover from crises while maintaining core functions. It involves proactive measures, crisis management, and post-crisis learning to enhance future preparedness. Given the uncertainty of future health threats, resilience becomes a crucial aspect of healthcare planning.

Some measures that countries can put in place include: identifying potential threats and developing strategic health information systems; diversifying primary healthcare services to manage a broad range of health challenges; instituting effective data collection and use to support evidence-based decision-making; and facilitating collaboration and coordination between various healthcare entities to allow for a more comprehensive and effective response to health threats.

Conclusion and key takeaways

The threats faced, from drug resistance and insecticide resistance to climate change and fragile healthcare systems, highlight the complex web of challenges to be addressed if we are to end malaria in Africa.

As we celebrate the achievements of the past, we must also harness this momentum to drive forward and intensify our commitment to research, innovation, and collaboration. Further, we must focus on strengthening healthcare systems to fully overcome the challenges and pave the way for ending malaria.

Read the summary of the first webinar here: https://bit.ly/3pSGBXB