Malaria in Africa today.

Malaria kills one child every 30 seconds and more than I million people annually in Africa. According to the Africa Malaria Report-2003, the disease continues to take its greatest toll on very young children, mostly under the age of five, and pregnant women south of the Sahara. New analyses confirm that malaria is the principal cause of at least one fifth of all deaths of young children in the region. In endemic countries, as many as one third of all clinic visits and at least a quarter of all hospital admissions are for malaria. The number of children dying from the disease rose substantially in eastern and southern Africa during the first half of the 1990s, compared with the 1980s.

The Summit on Roll Back Malaria, held in 2002 in Abuja, Nigeria, endorsed some relatively inexpensive yet effective control interventions already available, including insecticide-treated nets (ITNs) that have proven to be highly effective in reducing mortality in young children. The use of these nets helps prevent the disease, which is particularly important due to the increase in drug-resistant falciparum malaria parasites. There are now more children sleeping under nets and greater use of ITNs in Africa than ever before.

Their price has fallen substantially as a result of greater demand, increased competition among producers, and reductions in taxes and tariffs and other obstacles to trade that were introduced and implemented by many African countries after the 2002 Summit. At least five large African factories are producing the nets, and almost all malaria endemic countries in the region have active programmes under way to encourage ITN use. However, the commercial price of nets and insecticides is still unaffordable for the poorest of the population. Major efforts are being made in at least five countries to provide subsidized ITNs to young children and pregnant women.

On 26 September 2003, the United Nations Children's Fund (UNICEF), the World Health Organization (WHO) and the Acumen Fund announced a breakthrough in technology that embeds the net's fibres with insecticide and will not require retreatment for up to five years. Developed by Japanese researchers, they are known as long-lasting insecticidal nets (LLITNs). Until recently, when A-Z Textile Mills in the United Republic of Tanzania began producing them, they were manufactured only in East Asia. Producing them in Africa, however, will increase their availability and strengthen the development of the industry there. Although the initial cost of LLITNs is higher than conventional nets, they are more cost-effective than annual retreatment.

The Acumen Fund, WHO and UNICEF are appealing to producers and distributors based in Africa to make the low-cost, high-quality nets available quickly.

"We envision a range of highly effective, locally manufactured long-lasting insecticidal nets being produced in Africa within the next few years", said Dr. Lee long-Wook, Director-General of WHO. "Getting these nets to the people who need them will contribute in an important way in controlling Africa's number-one child killer in a sustainable way." In addition, many African countries had recently received funds for the purchase of nets from the Global Fund to Fight AIDS. Tuberculosis and Malaria, and some of these countries will purchase LLITNs.

The Africa Malaria Report also states that in most countries chloroquine--the most commonly available anti-malarial drug--has lost its clinical effectiveness. In addition, resistance to sulfadoxine-purimethamine--the most common replacement drug--has emerged. Over the past lew years, thirteen countries have changed their national policies to require the use of more effective anti-malarial treatments. Where current mono-therapies fail. WHO recommends artemisinin-based combination therapy (ACT), which delays the emergence of resistance, but so far its use has been constrained by high costs and limited operational experience. Four countries have adopted ACTs as first-line treatments.

Data from sample surveys indicate that almost half of all under-five-year-old children with fever are treated with anti-malarial drugs, which often fail, or are given too late or in the wrong dosage. Recent studies indicate that home treatment, when supported by public information and pre-packaging to ensure that patients take the full course of treatment at the right time, can help reduce mortality in children. Through support for community initiatives and the engagement of drug sellers and the pharmaceutical industry, many countries now concentrate on making effective treatment available close to home.

The Report also states that the impact of malaria on pregnant women and their newborns can be reduced substantially by the recently recommended use of "intermittent preventive treatment" (IPT) This provides at least two doses of an effective anti-malarial at routine antenatal clinics to all pregnant women living in areas in Africa at risk of endemic falciparum malaria, whether or not they are actually infected with the disease. About two thirds of pregnant women south of the Sahara attend clinics for antenatal care. Now an integral part of the WHO Making Pregnancy Safer. IPT has been adopted by six countries as a policy to replace chemoprophylaxis, and most other countries in the region are reviewing their policies in light of the new recommendation. The prevention and management of the disease during pregnancy calls for a combination of IPT, support for ITN use and prompt access to effective treatment. Five countries in eastern and southern Africa have recently formed a coalition to reduce through this method the impact of malaria in pregnancy.

Reported by Erika Reinhardt, for the Chronicle