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Expert opinion

Malaria Prevention and Control, Dr Kopano Mukelabai

What role does UNICEF play in the global effort to control malaria?

Mukelabai: Malaria kills an estimated 2 to 3 million people each year, the majority of which are children under five years of age. Every 30 seconds a child dies of malaria. The majority of our work has really been in the African region where 90 per cent of the malaria problem exists – the disease is still considered to be the major killer of children in sub-Saharan Africa.

Our overall goal is to reduce malaria by 50 per cent by 2010. To do this, UNICEF is working with several partners in the Roll Back Malaria campaign, an initiative launched in October 1998 by World Health Organization (WHO), UNICEF, United Nations Development Programme (UNDP) and the World Bank. Our focus has been twofold. First, we are working to make insecticide-treated mosquito nets available for children under the age of five and for pregnant women. Second, we are trying to ensure that those suffering from malaria have rapid access to treatment.

Why is it so important to protect children and pregnant women?

Mukelabai: In typical malaria-endemic areas, adults who suffer from malaria don’t die from it because they have built up immunity that protects them. We are much more worried about children under five, because they have not been exposed to malaria infections before and therefore their immunity to the disease is not yet fully developed.

During pregnancy, women also tend to lose some immunity against malaria.  Malaria during pregnancy contributes to anaemia, miscarriages, stillbirths and death. The newborn babies can also be born with low birth weight, which makes them more likely to die of complications of pneumonia, infections, and hypoglycemia. By preventing malaria during pregnancy, you reduce the incidence of lower birth weight by as much as 30 to 40 per cent. Also, if these women get treated nets, we are sure that the newborn children will be protected for the first three to five years of its life.

How do treated mosquito nets prevent malaria?

Mukelabai: Research has shown that if children under five and mothers sleep under these nets, it can reduce under-five mortality by 30 to 50 per cent. This is a very useful tool indeed and it is not expensive. Last year [2002] we procured up to 1.6 million nets with about $4 million, plus large quantities of insecticides, which are used to treat the nets every six months. The target at the moment is to have 60 per cent of the population sleeping under treated bednets by the year of 2010, especially children under five and pregnant women.

What are some of the ways UNICEF is working to achieve this goal?
 
Mukelabai: In many African countries the mosquito nets are simply not available, or, where they are present, the prices are too exorbitant for the families to afford. We are trying to stimulate local production of mosquito nets and trying to get the private sector involved because this brings down prices. In Tanzania, for example, the price of nets is only US $3 because there are three companies producing and promoting them. They actually go to the rural areas to sell their nets and the communities are starting to see the benefits.

In Kenya, we have been assisting micro-initiative programs that create a self-sustaining, revolving fund. Community health workers work together with village health committees to sell nets at a marginal price, not making any profit at all, so that they can buy more nets in the future. There are also a number of programmes in Mozambique where UNICEF has been working with the non-governmental organizations (NGOs) to sell and distribute nets in the remote rural areas. In the northwestern part of Zambia, the poor have been able to buy mosquito nets using a barter system. At harvest time, the people exchange maize, cassava or fish for mosquito nets and the village committee then sells the goods in order to buy more nets.

How is UNICEF working to help children who have malaria?

Mukelabai: Even if children sleep under mosquito nets, they can still get bitten during the evening before they go to sleep. Prompt treatment of malaria is critical. Sometimes waiting even six hours for a young child can mean the difference between life and death, because they may have severe complications within a short period of time. UNICEF is working with communities and governments to ensure that children have access to medications, even at the weekend when health centers are closed. A mother should be able to go to a drug store and purchase a dose of anti-malaria drugs to give her child. Our target is that by 2005, 60 per cent of those suffering from malaria should have access to treatment within 24 hours of onset of illness.

What are the challenges to achieving this goal?

Mukelabai: The key is to provide both effective and affordable treatment. Many health centers do not have the correct drugs for malaria or, if they do, they may be prohibitively expensive. An average child will suffer five or six episodes of malaria every year. Paying for treatment and transportation costs can be quite difficult for parents. This situation is exacerbated by the fact that the most widely used and affordable antimalarial drug, chloroquine, is increasingly ineffective. In many countries, it no longer works due to increasing drug resistance. The latest alternative – a combination antimalaria drug – costs as much as US $2.40 per course of treatment. We are hoping that the new fund for HIV/AIDS, tuberculosis and malaria will encourage the private sector to begin making drugs available at a cheaper price.

Where does malaria pose the biggest threat?

Mukelabai: The vast majority of malaria cases, 90 per cent, occur in Africa. However it remains a problem in Afghanistan, Brazil, Colombia, India, Sri Lanka and Viet Nam. Malaria is endemic in some of these countries, for some it is a seasonal problem and others may experience epidemics every two to three years. One of the challenges for us in the endemic countries is to combat the fatalism of the people who come to think of malaria as an intractable problem. In those regions where malaria is seasonal, there is also danger of complacence. For example, malaria is a major problem in Zambia but during the dry season people don’t see the mosquitoes and they stop sleeping under nets. But, there are still many young children who can develop severe malaria during the dry season.

What causes malaria epidemics?

Mukelabai: Epidemics often occur during emergency situations such as floods or conflicts, where you have displaced populations. Two years ago, there was a major epidemic of malaria in Burundi. Due to civil instability, people living in highland areas - where malaria is not a problem -– moved to the lowlands where it is a major problem. Both children and adults died of the malaria epidemic because they had little immunity.

 Availability of antimalarial drugs was also a major problem because of the conflict. UNICEF worked with several partners – WHO and Médecins Sans Frontières  – to fly in sufficient quantities of drugs. Similar  breakdowns in health systems has led to resurgence of malaria in Afghanistan and in Eastern Europe, where malaria had been very well under control.

What countries have successfully controlled malaria?

Mukelabai: In Africa, Mauritius has controlled malaria for the last 20 or 25 years. They have a very good surveillance system. If you arrive as a tourist in Mauritius, they are likely to test your blood at the airport, especially if you are complaining of fever. If they catch you with malaria, they treat you quite early. Their health system is also quite sophisticated.

In South-East Asia, Viet Nam has an excellent malaria control programme. The government went out their way to provide mosquito nets en masse to most families. They also provided insecticide to treat those nets on a regular basis. So they have increased the coverage of mosquito nets to well over 80 to 90 per cent of the population. They are also using rapid diagnostic tests. Instead of having to examine a blood sample under the microscope, they use a dipping technique that allows them to diagnose malaria very quickly. Furthermore, they have improved their treatment using the new combination drugs.

Looking forward, what are the long-term goals for combating malaria?

Mukelabai: Ultimately, if we can come up with an effective vaccine, this will be the answer to the problem. Unfortunately, the malaria parasites are very elusive. Some people believe we will find an AIDS vaccine much sooner than one for malaria. It is very complicated to immunize against malaria because the parasites keep changing their behaviour and morphology. There are two or three vaccines that are undergoing clinical review at the moment, but these are still in the area of clinical experimentation.

In terms of treatment, we are always looking for affordable alternatives to current drugs. We are also looking into the possibility of long-lasting nets. These are permanently-treated nets that are coated with insecticide at the factory and do not need to be retreated for three to five years. UNICEF is working with the private sector to see if there can be a transfer of technology so that smaller companies who are producing nets in African countries can have access to that technology.