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What is malaria?
Plasmodium falciparum, one of the most common of the four malaria parasites (the others are plasmodium vivax, ovale and malariae) and the most deadly, spreads through the bite of an infected Anopheles mosquito. This happens most frequently during the rainy season in certain climates and geographical regions.
Symptoms typically appear within 9 to 14 days after the infected bite and include fever, headache, vomiting, and other flu-like manifestations. If effective drugs are not available for treatment, the infection can rapidly become life-threatening.
In 2006, MSF treated more than 1.7 million people for malaria. Every year, malaria kills nearly 2 million people and infects 400 to 500 million, according to the World Health Organization (WHO). Ninety percent of these deaths occur in sub-Saharan Africa, but the disease is present in more than 100 countries and in nearly every tropical area where MSF has field programs, from Sierra Leone to Cambodia to Myanmar.
Children account for 75 percent of the deaths caused by this disease while pregnant women are also at high risk.
Malaria's effects are far-reaching and can wreak havoc on a socioeconomic level. Patients are often bedridden and incapable of carrying out normal daily activities, and children who survive the disease may suffer neurological damage. The results can be the loss of income and heavy burdens on families, health systems, and society as a whole.
But this suffering and loss of life are tragically unnecessary; malaria is largely preventable, detectable, and treatable.
Treatment and Prevention
Currently, the most effective treatment for malaria is artemisinin-based combination therapies (ACTs). Derived from the sweet wormwood plant, artemisinins have cured fevers in China for two thousand years, and for the last 30 years they have been used to treat malaria, primarily in Asia. Malaria has become resistant to older drugs such as chloroquine, formerly a very effective treatment, and sulfadoxine-pyrimethamine, although these are still in use.
The advantages of ACTs — few side-effects, easy and patient-friendly treatment, rapid action against the parasite — are widely acknowledged. The World Health Organization (WHO) declared ACT the preferred method for treating malaria in 2001, the same year that MSF began using them in its programs. Two years later, MSF started advocating for their use in national programs.
Today, 41 out of 54 African countries have officially changed their protocol to treat first-line malaria with ACTs. However, in many places where MSF works, ACTs are scarcely available. The global need for ACTs is estimated to be at 300 to 500 million treatment courses per year, however, in 2006, drugs for less than 90 million treatments were purchased. One of the challenges is the higher price of ACTs in comparison to older therapies like chloroquine.
The distribution of bed nets treated with insecticide has been an effective way to prevent malaria, according to the WHO, and MSF includes bed nets in some of its programs in malaria-endemic regions. Prevention without treatment, however, is ineffective, and often bed nets are not enough, especially when populations must flee their homes and belongings.
Better Treatment for Malaria
Two easier-to-use and more affordable malaria treatments have been introduced by the Drugs for Neglected Diseases Initiative (DNDi), a non-profit partnership launched in 2003 involving MSF, WHO, and public research institutes from Brazil, France, India, Kenya, and Malaysia, with the aim of researching and developing new, field-adapted drugs and drug formulations to treat neglected diseases.
Sierra Leone 2008 © Anna-Karin Moden/MSF
The new, fixed-dose combination (FDC) therapy ASAQ combines two drugs – artesunate and amodiaquine. Launched in March 2007, the treatment is for use primarily in Africa. DNDi introduced a second FDC in April 2008; ASMQ is the first drug against malaria that combines artesunate (AS) and mefloquine (MQ), and it was created for use in Asia and Latin America.
Of ASAQ, Dr. Michel Queré, medical coordinator for MSF in Chad, says "Combining those two drugs in one tablet is a significant improvement because it will make malaria treatment much easier for patients. Children, for example, will only have to take one — instead of four — tablets a day for a three-day treatment. This will increase adherence and reduce the risk of drug-resistance." In Chad, MSF medical teams treated nearly 80,000 patients for malaria in 2006.
ASAQ, which is manufactured and distributed in cooperation with the pharmaceutical company Sanofi-Aventis, costs less than US$ 0.50 for children under 5, and less than US$ 1 for adolescents and adults. In accordance with DNDi's mission — to focus on the needs of patients in low income, underserved regions — neither ASAQ nor ASMQ will be protected by a patent, allowing for different producers of the drugs and therefore greater price competition, as well as wider distribution.
Antigen tests for falciparum malaria, including one marketed as Paracheck®, are simple to use and produce results rapidly, making them adaptable for use in remote areas. MSF uses confirmed diagnosis, either through rapid tests or through microscope examination in laboratories, for all its malaria programs. But such tools are not used everywhere.
Diagnosing malaria based on clinical symptoms alone, and not by microscopy or rapid test, leaves significant room for error. However, clinical diagnosis is still the norm in many places. An MSF study carried out in southern Sudan confirmed that over-diagnosis of malaria is common. There is also the problem of self-diagnosis. Malaria is so common in Africa, many people who are sick assume they have the disease and will purchase malaria drugs on their own, often leaving the real reason for their symptoms untreated.
In spite of the existence of simple, effective testing tools and treatment, malaria continues to be the biggest killer of children under five years old in parts of sub-Saharan Africa. The problem often stems from cost. In Sierra Leone, ACT treatment is supposedly available for free to children under five years old and pregnant women, but people continue to die from the disease because they cannot afford the doctor consultation fee, the cost of additional medicines, or transportation to a clinic. Sometimes, the nearest health clinic is too far away, or the rainy season prohibits travel.
MSF is working on developing ways to meet these challenges. In Sierra Leone and Mali, MSF staff trains lay people as community malaria volunteers to deliver basic malaria care in villages far from a clinic. In Central African Republic and the Democratic Republic of Congo, MSF has trained health workers to bring care to displaced patients who are too frightened to leave the forest. Similar approaches are being used in Ethiopia, Chad, and Cambodia to reach remote or isolated areas.
Joseph Tucker is a 38-year-old farmer with four children in Bandajuma Village, Sierra Leone. He was appointed by his community to be a health volunteer, and received three days of training from MSF, learning about malaria and how to diagnose it and treat it.
“In my village, there are 145 children under the age of five and four pregnant women. Forty-three of the children and pregnant women I tested in the last three weeks were malaria-positive. Before this time, they would have had to walk three miles to reach the nearest clinic to get treated. Now, we even have people coming to our village from other villages because they know we have the tools to treat malaria,” Tucker says.
In southern Mali, MSF went a step further. In an area where 72 percent of the population lives below the poverty line, according to the United Nations Development Program, malaria is rampant, and people have little access to health care, MSF collaborated with the local health authorities to create a strategy for fighting malaria. By implementing free care for those most at risk and reduced fixed-cost treatment for those less at risk, and by training community health volunteers to test for and treat malaria, the project saw encouraging results. The mortality rate for deaths linked to malaria in community health centers fell from 0.35 percent to 0.03 percent between 2005 and 2007, while the rate of severe cases of malaria was reduced from 8 percent to 1.7 percent. Meanwhile, the total number of consultations more than quadrupled each year.
In 2000, the Roll Back Malaria (RBM) initiative set up by WHO, UNICEF, the World Bank, and others pledged to cut malarial deaths by half before 2010. However, people continue to suffer from the disease. In spite of radically improved diagnostics and treatments, the rates of death, illness, and socioeconomic disruption caused by malaria has not abated.
MSF has been treating patients with malaria in its projects in Africa, Asia, and Latin America since 1985 and has conducted numerous drug resistance studies in collaboration with national health ministries and Epicentre, MSF's epidemiological research institute.