2001-2010: Decade to roll back malaria in developing countries, particularly in Africa (A/64/302)
Item 49 of the provisional agenda*
Note by the Secretary-General**
The Secretary-General hereby transmits the report prepared by the World Health Organization in accordance with General Assembly resolution 63/234.
The present report highlights the progress made in meeting the goals concerning malaria to be achieved by 2010 in the context of General Assembly resolution 62/180. The report is based primarily on data collected for the World Malaria Report 2009, which will be published by the World Health Organization (WHO) in late October 2009. Additional data from demographic and health surveys, malaria indicator surveys and multiple indicator cluster surveys were openly available from a variety of Roll Back Malaria partners. The report also presents conclusions and recommendations for the consideration of the General Assembly.
There is increasing evidence that aggressive malaria control is having a large impact on all-cause child mortality. Significant reductions in mortality are now being demonstrated in parts of Africa where target levels of intervention coverage have been achieved. In some cases these reductions are even greater than expected from prior data. Initial evidence from Sao Tome and Principe, Zambia and the islands of Zanzibar (United Republic of Tanzania) points to a substantially higher reduction in child mortality than previously estimated: a greater than 40 per cent reduction in allcause inpatient child deaths if malaria inpatient child deaths are reduced by 90 per cent. This suggests that aggressive malaria control could be the leading edge for many African countries to reach, by 2015, the target of a two thirds reduction in child mortality as set forth in the Millennium Development Goals.
Nevertheless, malaria continues to kill approximately one million persons each year. Approximately one half of the world's population remains at risk of malaria, with 109 countries considered endemic for malaria, 42 within the WHO African region. Countries at the World Health Assembly and Roll Back Malaria partners have established the goal of reducing malaria morbidity and mortality by 50 per cent or more by the end of 2010 compared to 2000, and by 75 per cent or more by 2015. In September 2008, the Roll Back Malaria Partnership launched its Global Malaria Action Plan, in line with the best technical approaches recommended by WHO. The Plan defines the steps needed to accelerate progress towards achieving the Partnership's 2010 and 2015 targets for malaria control and elimination, sets the stage for the eventual eradication of malaria in the long-term and constitutes a single plan coordinating the efforts of Roll Back Malaria partners to achieve their shared goals.
Preliminary analysis suggests that the 2010 target was already being achieved or approached in 2008 by five African countries (Eritrea, Gambia, Rwanda, Sao Tome and Principe, Zambia) and by the islands of Zanzibar (United Republic of Tanzania). The Gambia, Rwanda and Zambia appear to have reached these targets, primarily with intermediate coverage of insecticide-treated nets and improved access to treatment with artemisinin-based combination therapies. Sao Tome and Principe and Zanzibar (United Republic of Tanzania) have already reached the 2015 World Health Assembly and Roll Back Malaria Partnership target of a greater than 75 per cent reduction in malaria mortality and morbidity using indoor residual spraying in addition to insecticide-treated nets and artemisinin-based combination therapies.
However, in some West African countries (Togo, Niger) and the high-transmission areas of western Kenya, the mass distribution of treated nets targeted to children and pregnant women only has not been followed by the same expected health impact.
Funding and commodities for malaria control increased again in 2007 and 2008, compared to 2000-2006. For example, since 2006, there has been a large increase in the procurement and distribution of long-lasting insecticidal nets (60 million in 2008); there are well-developed plans for even more rapid scaling-up in the next 16 months. According to the Alliance for Malaria Prevention, 21 countries have now procured 50 per cent of the insecticide-treated nets required to meet universal coverage targets. However, few have reached the World Health Assembly and Roll Back Malaria Partnership coverage target for 2010 of at least 80 per cent use of treated nets for all persons at risk, including children under 5 years of age and pregnant women. From available survey data, four countries (Ethiopia, Gambia, Sao Tome and Principe, Zambia) had reached 60 per cent or greater household ownership of insecticide-treated nets ownership in 2007 or 2008. In a number of countries, more aggressive communication strategies are needed to help close the gap between household ownership and use of the nets. On World Malaria Day 2008, the Secretary-General pointed to the need to ensure that every person had access to a mosquito net. Approximately 250 million long-lasting insecticidal nets are still needed to achieve the goal of universal coverage goal by the end of 2010.
The procurement of antimalarial medicines for the public sector also increased in 2008 compared to 2006-2007. However, access to treatment, especially of artemisinin-based combination therapy, was generally poor in countries with survey data available for 2007-2008. In nearly all of the surveyed countries (except the United Republic of Tanzania), the percentage of children under 5 years of age with fever who received an artemisinin-based combination therapy was less than 12 per cent. There are multiple reasons for this low coverage, including: stock-outs of such therapies at the national and health facility levels due to weak procurement and distribution systems, limited access to public health services and the high cost of the therapies in the private sector.
Eleven countries are implementing elimination programmes nationwide (Algeria, Azerbaijan, Egypt, Georgia, Iraq, Kyrgyzstan, Republic of Korea, Saudi Arabia, Tajikistan, Turkey, Uzbekistan), with eight of them having entered the elimination phase in 2008. Eight countries are in the pre-elimination stage (Argentina, Democratic People's Republic of Korea, El Salvador, Islamic Republic of Iran, Malaysia, Mexico, Paraguay, Sri Lanka) and making a programme reorientation towards a nationwide elimination approach. A further 8 countries have interrupted transmission (Armenia, Bahamas, Jamaica, Morocco, Oman, Syrian Arab Republic, Russian Federation, Turkmenistan) and are in the phase of preventing the reintroduction of malaria. If these countries can sustain zero cases for three consecutive years, they will be eligible for WHO certification as malaria free.
Both parasite resistance to antimalarial medicines and mosquito resistance to insecticides are major threats to achieving global malaria control targets. The first evidence of resistance to artemisinin-based combination therapies was found recently in western Cambodia and a rapid containment response is being coordinated by WHO with support from the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States Agency for International Development (USAID). Routine monitoring of antimalarial drug efficacy has waned in recent years, particularly in Africa. Regional and country-level capacity for this critical monitoring activity should be rebuilt, and appropriate funds allocated to ensure its regular execution. The continued use of artemisinin monotherapy is a major contributing factor to parasite resistance. Despite the call by WHO to halt their use, the production of artemisinin monotherapies continues and many countries have not yet withdrawn these medicines from their markets. To meet this goal, greater assistance will need to be provided to national drug regulatory authorities.
Although monitoring for insecticide resistance should be an integral part of scaling up insecticide-treated nets and indoor residual spraying, it is currently insufficient in most countries. Entomologic capacity-building at the regional, subregional and national levels will be critical to conducting this monitoring and mitigating the threat of insecticide resistance.
Over the past year, intervention coverage is increasing in Africa and globally, and an impact has been confirmed in those countries with prior low-moderate transmission of malaria and higher intervention coverage. To reach the World Health Assembly and Roll Back Malaria Partnership impact targets for 2010, malaria interventions need to target all persons (instead of just children and pregnant women), especially in high-transmission countries. Impact needs to be monitored closely to ensure that disease control targets are being met. Outside of Africa, significant progress has been seen in a number of countries but the number of cases has fallen least in countries with the highest incidence rates. Control efforts need to be intensified in countries and areas with the highest malaria burden before the Millennium Development Goals can be achieved.
Nearly all of the one million malaria deaths each year could be prevented with the universal application of existing tools.