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Progress for child survival: Malaria

Listen to Professor Chris Whitty describe the progress made in reducing child deaths from malaria.
CHRIS WHITTY: Historically, malaria is one of the major diseases killing children across the tropical countries. Over the last 15 years, we’ve had a significant reduction in malaria– a really remarkable reduction– and it’s gone down by over 50% in the period between 2000 and 2013, and it’s still falling. So the question is how this has been achieved. And broadly it has been achieved in two different ways– by prevention and by treatment. Now starting off with the prevention, malaria has one advantage, and that is that it’s passed on by mosquitoes. So this gives us two possible ways of trying to prevent it– attacking mosquitoes and protecting the child directly.
Now the key thing that’s happened over the last 15 years is the introduction of long-lasting insecticide-treated bed nets. And we’ve got those from a rate of below 3% at the turn of the century up to almost 50% now. These protect the children under them but they also kill infected mosquitoes, so they protect other people as well. Additionally, historically, we’ve always used spraying insecticides on walls where infected mosquitoes land. And we still use that, but it’s a less important part of what we do. And more recently we’ve moved over to the other side and are looking at how we can protect children by giving them drugs which prevent malaria.
And this particularly works in cases where there’s intense malaria but it only occurs for a short period of the year, for two or three months. So the children only have to take the drugs for a few months. But that protects them very substantially across the whole year. When it comes to treating malaria in children we fortunate have extremely effective drugs at the moment. And we now have diagnostic tests which even people out in peripheral clinics and in shops can use effectively to target the treatment to the people who need it. Because of this, really no child should be dying of malaria.
And yet still at the moment 450,000 children a year are dying of malaria, all of whom could be cured with relatively cheap and available drugs. So we’ve had big advances over the last decade, but we clearly need to go a lot further. And problem we really have is one of targeting– almost all those children who die of malaria aren’t given drugs, they haven’t got to a place where drugs are available. And yet anti-malarial drugs are often given to people who don’t have malaria. So getting the drugs to the right people is really the next major challenge in terms of treating malaria if we’re to push down the mortality rate a lot further.
I would highlight three challenges which we’re having to face with malaria looking over the next decade. The first of them is that the very effective insecticides and drugs that we have at the moment will gradually be lost because of mosquitoes being resistant to insecticides and the parasites being resistant to the drugs. There’s now drug-resistance in Southeast Asia that’s spreading steadily across the rest of Asia and will eventually reach Africa. And there is insecticide resistance now growing in Africa. This means we’re in a kind of arms race where we really have to massively increase the number of drugs and insecticides available. And the question is, will we have available by the time we lose the current drugs?
And that’s I think is– there’s a good pipeline, but we’re not there yet. So that’s the first challenge. The second is one of delivery. We can actually reduce virtually all of the deaths we have at the moment to very close to zero if we could just get all the right drugs to all the right people. And this delivery challenge we haven’t yet completely finished working out how to do that. And the final thing is that will be victims of our own success in two separate ways.
The first is that as malaria incidence– how frequent it is– goes down, it’ll move from an endemic disease– that’s a disease that affects, only, essentially, children in terms of the serious disease all the time– to epidemic disease where it comes in sudden waves, affecting the whole community. So this change of how malaria is going to present in Africa is a serious challenge for the future. And the other is the political support for malaria is currently very strong, but as diseases become less important inevitably their relative importance decreases. And there’s a risk people will take their eye off the ball and will actually pull away from malaria.
And what we know from history is as soon as you pull away from malaria it comes roaring back. Currently one of the really big debates in malaria is between those say that we want to eliminate malaria– that means stop it being transmitted completely wherever we can– and those who want to reduce the number of deaths from malaria. Clearly we need actually to do both. But we need to be aware of the fact they’re in different places. So the really heavy burden of malaria is an African countries where the chance of elimination is a very long way in the future.
But there are some parts of the world– like southeast Asia, like Latin America– where we really could eliminate malaria, get rid of it completely. And it may well be this is the moment in time we really should do that so that people never have to think about it in those areas.

Moving on from HIV and AIDS, in our second example Professor Chris Whitty looks at a fast-reducing but major cause of child deaths: malaria. Half of the world population is at risk of malaria, and 90% of deaths occurring as a result of the disease are in Sub-Saharan Africa. Most of these deaths occur in children.

Malaria deaths are now reducing by around 4.5% each year, which represents a 53% reduction between 2000 and 2013. This has been achieved primarily through:

  • Massive scale up of use of insecticide treated nets (ITNs)
  • Treatment of malaria in children through rapid diagnostic tests and combination therapies (ACTs).

Challenges to maintaining the reductions cannot be ignored, and these include increasing resistance to ACT and insecticide, issues with delivery of drugs, and the problem of epidemic malaria.

There is a real chance to eliminate malaria entirely in some parts of the world. How do you think we can we strike a balance between investing in the elimination of malaria in low transmission areas, for example Southeast Asia, and bringing down mortality and morbidity in high transmission areas, such as Africa?

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