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The challenge

The Challenges

Children | Pregnant Women | Malaria and Poverty | Links to Other Diseases | Drug Resistance | Funding 

The challenges

Children and malaria

In Africa malaria is the biggest killer of children under five years old, who account for with nearly 90 percent of all malaria deaths. It is estimated that a child dies every minute from the disease.

Young children are much more vulnerable to all forms of malaria. In infants this is because their immune systems are not yet fully developed, while in under fives they have not yet developed effective resistance to the disease.

Malaria can have a devastating effect on children’s education. Repeated infections cause children to miss large periods of school and anaemia, a side-effect of frequent malaria attacks, interferes with children’s ability to  concentrate and learn and causes chronic fatigue. Repeated illnesses from malaria can also exacerbate any malnutrition, which can both decrease the effectiveness of anti-malaria drugs and increase children’s susceptibility to the other main killer diseases: diarrhoea and pneumonia.

The impact of malaria on children remains a serious obstacle to the achievement of many of the Millennium Development Goals (MDGs), including Goal 2 (universal primary education) and Goal 4 (the reduction of infant mortality).

Pregnant women and malaria

Why malaria in pregnancy matters
Pregnant women are particularly susceptible to malaria partly because of their reduced immunity to the disease but also because of their vulnerable social and economic status. Compared with those who are not pregnant, pregnant women are more likely to suffer from severe malaria and more likely to die from the disease.  
Malaria also causes severe anaemia, exacerbating the increased risk already present due to the extra demand of the growing foetus. Anaemia is associated with increased risk of pre- and post-partum haemorrhage which is a major cause of maternal death.
Unborn babies are also at risk, as malaria infection during pregnancy leads to infection of the placenta, which increases the risk of miscarriage and low birth weight delivery. Intra uterine growth retardation and low birth weight remain the most important risk factors contributing to newborn deaths and health complications that can last well into adulthood.
In Africa, it is estimated that a lack of prevention mechanisms for malaria in pregnancy would result in 11.4 million pregnancies with placental malaria infection, accounting for 41 percent of an estimated 27.6 million live births per year. Malaria is thought to contribute to between 10 and 25 percent of all maternal deaths in endemic areas and lead to 900,000 low birth weight deliveries each year. 
In Asia although the burden of malaria is less, malaria in pregnancy is even more difficult to prevent and manage. Firstly, pregnant women have little immunity as transmission is low. Insecticide treated mosquito nets are also less effective as mosquitoes tend to bite outdoors and in the early evening. Lastly, there is high resistance to the preventive medication, Sulphadoxine/Pyramethamine (SP) used in Africa.  New strategies need to be developed to prevent and manage malaria in pregnancy in Asia, looking at different preventive drugs or screening and treating all pregnant women at antenatal checkups.
Malaria in pregnancy is preventable
The World Health Organization (WHO) recommends a combination of three interventions for the prevention and treatment of malaria in pregnancy in endemic areas where transmission remains high and preventive methodologies remain effective. These are:
1.       Use of long-lasting insecticidal nets
2.       Intermittent preventive treatment in pregnancy (IPTp)
3.       Prompt diagnosis and effective treatment of malaria infections.
If these three interventions are implemented consistently, the burden of malaria in pregnancy in Africa could be reduced significantly.
Spotlight on IPTp
IPTp involves the administration of curative doses of an antimalarial drug to all pregnant women, regardless of whether or not recipients are infected with malaria. This approach is considered effective mainly because it is cheaper and easier to implement than testing and treating only infected women.
The drug used for IPTp must be efficacious, low-cost, safe and acceptable to pregnant women. IPTp is typically delivered to pregnant women as part of routine antenatal care visits. To maximise protection, WHO currently recommends the provision of IPTp at each scheduled antenatal care visit after the 13th week of pregnancy, allowing 28 days between doses. Women following the recommended schedule would receive IPTp three or more times.
Ambitious targets have been set for the provision of IPTp. For example, the Roll Back Malaria Partnership envisages 90 percent coverage with three or more doses of IPTp in areas of stable malaria transmission by 2030. However, despite generally high antenatal care attendance, most countries in sub-Saharan Africa do not come close to meeting this target. In Uganda, for example, current surveys suggest that only about a quarter of pregnant women receive two doses of IPTp. This suggests that many opportunities for the provision of IPTp are being missed.
Long lasting insecticidal nets are another strategy to prevent malaria in pregnancy. Mosquitoes are more attracted to pregnant women, so it is especially important that they sleep under a net every night. Behaviour change communication programmes have focused on the use of nets by pregnant women and in some countries nets are routinely given to pregnant women through antenatal care centresto ensure that they have one.

In some countries, there is a debate as to whether IPTp should be replaced or supplemented by a programme of screening and treating women for malaria during their pregnancy. Screening programmes have been shown to be as effective as IPTp in research settings and may need to replace IPTp should resistance to SP increase.

Malaria and Poverty

The cost of malaria to Africa is estimated at $12.5 billion per year, which represents 1.3 percent of affected countries economic growth (GDP). In some countries, malaria accounts for up to 40 percent of total health expenditure and 20-50 percent of hospital admissions. Productivity is reduced and staff turnover increased by illness-related absenteeism and children’s education is severely disrupted. Rural and poor populations carry the overwhelming burden of malaria because access to effective treatment is extremely limited. In rural areas, infection rates are highest during the rainy season - a time of intense agricultural activity. Research indicates families affected by malaria harvest 60 percent less crops than other families.

Links to Other Diseases

Malaria-endemic countries are also plagued by diseases such as tuberculosis, polio, cholera and HIV/AIDS. These diseases have a cumulative effect, with one reducing a person’s ability to cope with another. HIV/AIDS sufferers are at a higher risk of malaria morbidity and malaria reduces the survival rate from AIDS. Vertical, un-integrated, disease-specific intervention programmes have exacerbated the problem as they do not allow for the overarching aim of achieving universal coverage of malaria control interventions.

Drug Resistance

In 2008, the first cases of resistance to artemisinin-based drugs were confirmed in Southeast Asia along the Thai-Cambodia border. Currently, the most effective malaria drugs are derived from artemisinin and used in combination with other drugs. The use of two different drugs together aims to ensure parasites resistant to one drug are killed by the other before resistance is transmitted. The spread of artemisinin resistance from Asia to Africa would be a devastating to malaria control and elimination.

Funding for malaria

 Funding for malaria control has increased dramatically in recent years, from $592 million in 2006 to over $1 billion in 2008, and $1.7 billion in 2009. The Roll Back Malaria Partnership estimates $5.2-$6 billion a year will be required to acheive  Global Malaria Action Plan targets for 2015. The current global recession is likely to decrease aid spending making funding for malaria uncertain.

History shows malaria control efforts must be sustained in order to be effective. In Sri Lanka malaria was nearly eliminated  by 1963, but eradication efforts were not sustained and the disease returned. By 1990 there were 250,000 cases. Fortunately, control measures were stepped up again and in 2008 there were only 673 reported. It is therefore crucial that financial contributions continue to grow to sustain malaria control programmes.