Malaria is the world’s most deadly parasite, killing hundreds of thousands of people and infecting over 200 million every year - mostly children in Africa. This suffering and loss of life is all the more tragic as malaria is preventable and treatable. Doctors Without Borders/Médecins Sans Frontières (MSF) treated 2.4 million cases of malaria in 2018 in some of the most at-risk, hard-to-reach parts of the world.
What causes malaria?
Malaria is a parasitic infection spread by the bite of infected female Anopheles mosquitoes, which acquire the parasite when they bite an infected person. Once inside the human body the parasites make their way to the red blood cells, where they multiply rapidly until the cells burst and release even more parasites into the bloodstream.
Which groups are most at risk?
Infants and children under five years old are especially vulnerable to infection and serious consequences of malaria since they haven't yet developed immunity. People displaced from their villages because of conflict or natural disaster are also at an increased risk of malaria. Those coming from non-malaria areas lack the partial immunity developed by continuous exposure since childhood; when infected, they tend to get very sick. They also often live with poor or no housing in overcrowded camps near water and livestock, all of which contribute to malaria transmission. Pregnant women are at an increased risk of anemia, severe sickness and death when infected with malaria; there is also a higher chance that the pregnancy will develop complications or end in miscarriage, or cause fetal growth restriction.
What are the symptoms of malaria?
Malaria often begins as a flu-like illness. Fever typically appears 9-14 days after infection (typical cycles of fever, shaking chills, and drenching sweats may develop) and may be accompanied by multiple non-specific symptoms, which makes clinical diagnosis difficult. The disease also causes destruction of red blood cells, leading to anemia. If simple malaria is not treated it can become severe, increasing the risk of death. That’s why early diagnosis and quick treatment are vital. In severe malaria parasites may attack the brain, causing convulsions and coma and leading to breathing problems, kidney failure, and/or severe anemia. Each year about eight million malaria patients develop life-threatening complications.
How can malaria be prevented and controlled?
Malaria-carrying mosquitoes usually bite from dusk to dawn. Since mosquitoes breed in water they are especially plentiful during the rainy season, causing malaria infections to increase. The most basic prevention is to avoid bites through indoor spraying of homes with safe, long-lasting insecticides and by sleeping under bednets treated with long-lasting insecticide. More recently, antimalarial drugs have been used to prevent infection among the most at-risk populations for limited periods of time. Seasonal malaria chemoprevention (SMC) is now recommended for children during the four highest-transmission months in some regions. Preventive drug treatment is also recommended for pregnant women at routine prenatal care visits after the first trimester of pregnancy.
How is malaria diagnosed?
Diagnosing malaria is usually done with rapid diagnostic tests using blood from a finger prick. The tests are easy to perform, and community health workers can be trained to do them. A more accurate test is done by using a microscope to look directly for malaria parasites in a drop of blood. But most primary health facilities don't have microscopes or trained lab technicians, and microscopy is much more labor-intensive, So this diagnostic test is often not feasible. In some settings, neither test is available so community health workers must diagnose sick children based on symptoms alone. This often leads to the overdiagnosis of malaria while the real cause of patients’ symptoms goes untreated.
How is malaria treated?
The most effective treatment for malaria is a combination of two drugs as artemisinin-based combination therapy (ACT), which cure most infections in three days. Early treatment is essential since the longer the disease lasts, the more likely it will progress to severe malaria. Severe malaria requires hospitalization so patients can be given intravenous antimalarials along with supportive treatment. Patients often need blood transfusions, which in turn requires a safe, adequately-stocked blood bank—something that’s difficult to achieve in under-resourced areas, especially in sub-Saharan Africa. Without treatment, or with significantly delayed treatment, severe malaria kills. Treatment with artemisinin is usually very effective but the malaria parasite has developed resistance to artemisinin in some regions, particularly in Southeast Asia, meaning that ACT may no longer be effective. If the spread of resistance cannot be stopped, it could mean a resurgence of malaria, since there aren’t currently any new drugs available.
How MSF responds
Malaria is one of the most common diseases MSF treats. A big part of our efforts is focused on South Sudan, Democratic Republic of Congo, and Central African Republic, where the numbers of malaria cases and deaths are sometimes rising despite overall downward global trends. Our malaria strategy is focused on improving prevention, reaching and treating the most vulnerable, improving prevention, and enhancing advance planning for malaria seasons in the most affected regions where we work.
Reaching the hard-to-reach
One of the biggest challenges MSF faces is getting malaria care to those that need it the most: those living in remote, insecure areas with little or no health care access. Whether because of seasonal rains that flood roads or active armed conflict that forces people to leave their homes, finding better ways to effectively reach and treat our patients where they are is a challenge MSF is always trying to overcome.
One strategy is to use mobile clinics that travel to remote villages without health clinics nearby. For example, in the Central African Republic, many regions are isolated because of armed conflict, which has disrupted the already weak government health services. There is no public transportation for people to travel to larger towns. MSF mobile clinics drive two to three hours to visit remote villages to test for and treat malaria, transferring those already severely sick to hospitals.
Another strategy is to train and equip community health workers with supplies for providing care in areas MSF teams can’t reach consistently reach. In South Sudan, MSF has de-centralized simple malaria care by training community health workers who can test for and treat malaria in clinic teams. When people are forced to leave their homes because of fighting nearby these health worker teams move with them, since they are part of the community, and continue providing healthcare. The teams run clinics wherever they are six days a week, caring for thousands of people displaced by the ongoing conflict. while on the move. MSF re-supplies them with tests and drugs when security allows.
Community health workers in all projects also pass on vital educational messages about the importance of using bednets wherever possible and seeking treatment for children when they have fever.
Our programs incorporate various prevention approaches, depending on context—from distribution of bednets to spraying larvicide to prevent the breeding of mosquitoes. In some affected regions malaria is highly seasonal, with the number of infections increasing exponentially during the few months of the rainy season. In 2012, MSF began implementing a strategy called Seasonal Malaria Chemoprevention (SMC) in Mali and Chad to combat these predictable yearly spikes in malaria infection. We later expanded SMC activities to several countries of the Sahel, leading to reductions of 60-80 percent in the numbers of uncomplicated and severe malaria cases. In these programs, our teams distributed anti-malarial medications at the beginning of each month to as many children possible in the at-risk region during the rainy season. Now, we give preventive antimalarials to over five million children. In 2015-2016 we handed over most of these programs to national Ministries of Health for implementation, but continue to implement SMC in a few settings.
Innovating against resistance
In Southeast Asia, a key epicenter of resistance to anti-malarial drugs globally, our projects are actively researching the emergence of artemisinin-resistant malaria and piloting strategies to combat it. Since 2015, MSF has been implementing the Targeted Malaria Elimination (TME) program in Cambodia, working to find and treat patients with artemisinin-resistant (ACT) strains of malaria, and along the way adapting strategies and tools to better meet the challenges of resistance and malaria elimination.
Malaria spikes are too often treated as an unpredicted emergency despite the fact that we now have tools—from weather monitoring to close surveillance of new cases—to anticipate the onset of malaria peaks. Countries need to use these tools better to prepare for seasonal outbreaks by pre-positioning preventive antimalarials and bednets that can be distributed once the rainy season begins and by investing more in community-based care.
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