May 20, 2002

Posted to the web May 20, 2002

Lagos

Malaria is a scourge that has decimated the African population is an under statement. Second only to the AIDS pandemic in its death toll statistics, Sefy Megafu writes on the ravaging killer-disease and efforts being made by African countries to contain it

Since Hippocrates discarded superstition as a cause for the fever that affected ancient Greeks through the recognition of seasonality of the fever and clinical manifestations, in the fifth century B.C., Malaria has been declared 'deadly'. Serious attempts to eradicate it began in the mid 1940s with international cooperation. The first expert committee on Malaria was established by the Interim Commission of the World Health Organization (WHO) meeting in 1947. Subsequently, WHO was officially formed the following year with bias to eradicating mosquito vectors that transmit the parasite. Consequently, Western nations set on a series of global mass insecticide spraying with DDT on almost all the continents.

Sub-Saharan Africa was excluded from the eradication programme on grounds that malaria problem was enormous and that the region lacked technological capacity. This strategy was to be revised by the World Health Assembly when it became apparent that success was not technically or economically feasible in some regions of the world.

WHO therefore, adopted a new approach aimed at encouraging control where eradication was impossible. Even as this involves a long-term commitment of personnel and financial resources, the body did not increase funding of malaria control strategies that are to be integrated into basic health service programmes of individual countries to the disappointment of African leaders who now advocate for a massive continental insecticide spraying programme.

They contend that Roll Back Malaria (RMB) merely aims at controlling the disease and would enable purchase of malaria drugs, insecticides, mosquito coils as well as chemically treated nets from the West. They argue that it makes more sense if the huge sum of money sourced by all the international agencies would be for the eradication of the disease instead of control while stating that North America, South Africa, Russia and some European and Asian countries were formerly mosquito infested.

Two years ago, over 50 African Heads of States, heads of international organizations, 12 development and health ministers of different countries attended a Roll Back Malaria Summit in Abuja. The summit, which was convened by President Olusegun Obasanjo with the support of WHO reviewed the available research evidence on the impact of malaria on health, economic and human development in African countries. At the event, a declaration was made by the heads of states to actualise previous commitments by reducing the health and socio - economic burden of the disease especially in children under five years of age and pregnant women through treated nets and Inter Preventive Interventions.

But Malaria Care Organization in Africa (MACOA) criticized the Abuja conference, stressing that it dwelt only on control of the disease without a view of eradicating it. It insisted that the Roll Back Malaria initiative could easily be replaced with Roll off Malaria to enable meaningful participation in the programme. According to the organisation: "the argument of one donor agency that malaria control is the only programme suitable for Africa is rejected by MACOA. The opinion of the donor agency that anopheline female mosquito cannot be eradicated from Africa because Africa is too poor to provide sufficient funds for mosquito eradication is not sound. A third opinion by the same donor agency that the African is too disorganized and too corrupt to embark on such a scientific feat is itself not scientific and unacceptable to MACOA. >From wherever we roll back malaria, it shall surely re - surface in the near future..... Certainly Africa will not be in this sorry state forever."

Now, researchers claim that malaria has re - emerged in many non - African countries after the global mass insecticide spraying campaigns in the 1950s and 1960s which excluded Africa. It is said to be a serious problem in these parts of the world. Its return to China is overwhelming.

According to WHO, nearly five times malaria cases were reported in 1999 as against tuberculosis, AIDS, measles and leprosy cases put altogether. This definitely has caused some serious concern in Europe. Statistics indicate that in 1997, 12,000 cases of malaria that caused several deaths were reported among international travelers from Europe. Geneva, Brussels and Oslo have recently witnessed outbreaks of 'airport' malaria while in Tajikistan, the civil war led to its re - emergence and the number of reported cases were as high as 616 in 1993 to 30,000 in 1997.

The situation of the disease world over deteriorated due to relaxation of control measures and increased drug resistance. As such a WHO ministerial conference held in Amsterdam in 1992 enjoined health ministers, health workers, the UN, non governmental organisations and the scientific community to support a global malaria control strategy. The 1997 Harare Conference of African Heads of States gave rise to 1997 African Initiative. It was backed by WHO and eventually led to Roll Back Malaria in 1998.

But more poignant is the belief that malaria control may have far reaching implications beyond the current geographical boundaries of the disease. Scientists have since concluded that global temperature affect the prevalence and incidence of tropical diseases such as malaria. They have also warned that without adequate control malaria would spread like wild fire. Even as the UN General Assembly included malaria control as part of the health component of the UN special initiative on Africa, African leaders seem to be making a head way on how best to contain the problem. The Abaja conference was said to have boosted the commitment of the African leaders.

Still, doubts have surfaced in some quarters concerning the pledge made by the African leaders to drop import taxes on treated mosquito nets in a bid to control the disease. The Abuja Declaration on RBM in Africa, two years ago, stated, "We, the Heads of States and Governments of African countries... pledge to reduce or waive taxes and tariffs for mosquito nets and materials, insecticides, anti-malarial drugs and other recommended goods and services that are needed for malaria control strategies." A report available to THISDAY asserted that fewer than half have kept the promise.

In the report, Massive Effort, a global initiative that is mobilising society to fight AIDS, tuberculosis and malaria, declared that 26 countries have not removed taxes and tariffs on treated mosquito nets. "Africa's leaders must be held accountable to their promises", said Louis Da Gama, Director of Malaria Foundation International and spokesperson for the campaign. "They have it in their power to drop the taxes and to do more to fight malaria in their countries." Countries like Angola, Botswana, Burkina Faso, Burundi, Central African Rep., Congo, Democratic Repulic of Congo, Djibuti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Guinea, Guinea - Bissau, Madagascar, Malawi, Mauritania, Niger, Rwanda, Sao Tome, Principi, Sierra Leone, Somalia, South Africa, Swaziland and Togo have failed to live up to their promises while Nigeria, Benin, Cameroon, Chad, Cote d' Ivoire, Ghana, Kenya, Liberia, Mali, Mozambique, Namibia, Senegal, Sudan, Tanzania, Uganda, Zambia and Zimbabwe have complied with the pledge.

The disease reproduces sexually in the gut of certain species of mosquito and is transmitted to humans when the insect bites and takes a blood meal. The sporozoite stage which is present in the saliva is injected during the feed circulating in the blood until it reaches the liver where it invades hepatocycles and develops into a merozoite. The merozoite are to leave the liver cells, invade red blood cells in large number and cause malaria fever. the disease is associated with symptoms of cough, fever, vomitting, diahorrhea and loss of appetite. Febrile convulsion is another common symptom of severe malaria with high Case Fertility Rate (CFR). The seriousness of the disease cannot be overemphasized as the ailment becomes burdensome though the cornerstone of management is early and prompt treatment.

Febrile Statistics reveal that about 500 million people contract the disease that results to three to five million deaths. About 20 per cent of the world's population is at risk of Malaria in countries where it is endemic and over 90 per cent of the deaths occur in sub-Sahara Africa. The dire consequences of the ailment cause chronic illness especially in children, anaemia in women, low birth weight in babies and high mortality rate of children under five years.

It has been reportedly, about twenty African countries are endemic to malaria and another 20 are likely to be same. Fear is that the growing resistances to current anti-malarial drugs, multi drugs and insecticides pose threats. For instance, half of the malaria infections in East and Central Africa are resistant to Chloroquine. Although the epidemiology of the disease varies with climate, health system failure, drug resistance, population movement, deteriorating hygiene and climatic change and some other factors have contributed to the spread of the disease.

Unfortunately, in some cases, strains of malaria have developed resistance to four leading anti malarial drugs. Currently, experts are undergoing studies to ascertain the depth of this claim.

Dr. Abdul Raheem Mohammed of Faculty of Medicine, University of Khartoum, Sudan, at a seminar, recently organized by MACOA to mark the Africa Malaria Week informed that a study done in Halfa, eastern Sudan indicated an increase in resistance to Chloroquine and an emerging resistance to quinine and multi drugs. He stressed that malaria accounts for more than 40 per cent of infections in Sudan.

According to him, malaria is a serious complication during pregnancy and pregnant women should be treated with care. He advocated the use of quinine in the treatment saying " Quinine is a safe drug and should be used in pregnant women especially women with severe Malaria. Malaria can cause problems more than quinine". Speaking about new borns, Dr. Elizabeth Disu of the department of Pediatrics, Lagos State University Teaching Hospital (LASUTH), who spoke on neonatal malaria, observed that the disease occurs within the first phase of life of new born babies through their mothers by transmission of blood infested parasite.

She stated that malaria in the newly born is increasing in clinical practice based on various studies in epidemiology. Though epidemiology of malaria endemic areas is thought to be rare, it has been found to be present in babies in the first six months of their lives. The cause, she said is uncertain but could be as a result of hitches in the placenta wall. "Majority of the infants had problems in the first one week of life. The cases had lower haemoglobin level than the control".

Already, the incidence of cerebral malaria, a severe form of the ailment that affects the brain is also high. Dr. Fatima Abdul Kareem who participated in a post mortem review of 'a seven-year retrospective autopsy study revealed that between 1990 to 1997, out of 65 cases, 46.5 per cent cases of malarial deaths were due to cerebral malaria. 66 per cent of the cases were under ten-years of age, 63 per cent of the cases occured at the age of ten, while about seven per cent was under five years of age. Death was attributed to acute malaria in 75 cases. She also emphasized that males appear to be more vulnerable to the disease at the ratio of M : F =2:1. Other malarial deaths recorded were viewed as a result of cerebral oedema, tonsilar cowing, severe anaemia and anaemic heart failure. Abdul Raheem who noted that in a previous study percentage of death, 45.6 as caused by cerebral malaria as against the present 63 percent, concluded that there was an increase in the number of people, who die of the ailment.

As the search for malaria vaccine lingers, a candidate vaccine tested recently in West Africa provided partial protection against the parasite Plasmodium Falciparum which causes the disease. The vaccine RTs, S/ASO2 is the first of its kind to militate against the parasite. Though the immunity is short lived in adult, it has proved effective on children.

Meanwhile, anti-malarial drug Combination Therapy (CT) is resorted to in areas of intensive malaria transmission in Africa. The World Health Organization (WHO) in its programme to Roll Back Malaria has urged countries to switch to a new type of combination therapy when there is resistance to existing conventional medicines. It advocates that countries should begin the transition as soon as levels of resistance exceed 15 per cent and that the change will be implemented before resistance reaches 25 per cent.

The Artemisinin-Based Combination Therapies (ACTs) are said to have been derived partially from a Chinese herb and acclaimed as prospective in new malaria treatments. They kill the malaria parasite very fast, allowing the patient to recover quickly with few side effects.

Because the drug combines two medicines which work in different ways, it is believed that the malaria parasite having developed resistance to other single treatments would find it difficult to resist this combination.

WHO has just added one of the combination medicines (artemether/lumefantrine) to its Essential Medicines List,which prioritizes essential medicines for countries. The medicine, known as Coartem is the only medicine, which combines an artemisinin and non-artimisinin compound in a single tablet. WHO also recommends other combinations of artemisinin compounds with currently used medicines, such as amodiaquine or sulfadoxine-pyrimethamine, for use where these medicines are still effective.

To this end, the Board of the Global Fund to Fight AIDS, TB and Malaria, meeting in New York, decided to fund proposals to Roll Back Malaria in Zanzibar and Zambia. The proposals include purchase and introduction of the ACTs.

"We hope that the fund and other funding mechanisms will be used to purchase ACTs where they are needed to treat malaria and improve the control of the disease in communities at risk" said Dr. Gro Harlem Brundtland, Director-General of the organization who also added that WHO has been in partnership with variety of manufacturers to reduce the price of ACTs in developing countries. "It is important that countries which need ACTs are able to access and use them in a sustainable manner", the Director-General added.

Also as a result of the strong resistance to Chloroquine, many countries have resorted to sulphadoxine-pyrimethamine (SP) or Fansidar as first line treatment. But resistance to SP is also fast spreading.