According to the World Health Organization’s World Malaria Report, there were 263 million cases of malaria in 83 countries in 2023 compared to 252 million cases in 2022 (WHO, 2024). The estimated number of deaths due to malaria was 597,000 in 2022 compared to 600,000 in 2022.
According to the World Health Organization, the African region continues to dominate the global malaria burden. In 2023, the region accounted for 94% of malaria cases and 95% of deaths. Children under 5 years of age accounted for about 76% of malaria deaths in the region. More than half of these deaths occurred in four countries: Nigeria (30.9%), Congo (11.3%), Niger (5.9%) and Tanzania (4.3%).
1. Current status and challenges in malaria elimination in Africa
There are currently 5 species of malaria parasites. Plasmodium spp. cause malaria in humans and two of the five species are predominant in malaria‐endemic areas. P. falciparum and P. vivax, These two species pose the most serious threats. P. falciparum is the most lethal malaria parasite species among those endemic in most African countries. P. vivax is also the predominant malaria parasite in countries outside sub‐Saharan Africa. Other species that can infect humans include P. malariae(Recently discovered more in some areas), P. ovale and P. knowlesi.
Africa is facing a number of threats to its progress towards eliminating malaria in Africa by 2030. Despite political will and awareness, the lack of resources to defeat malaria according to national plans, maintain vital services for the entire population and deploy new and effective interventions has led to an increase in biological threats. Together with the global community, African leaders must act now to push back and end malaria.
Figure 1. Movement and malaria infection when returning from malaria‐endemic areas
2. Progress and challenges in eliminating malaria in Africa by 2030
According to WHO, an estimated 236 million malaria cases (95% of global cases) and 590,935 deaths (97% of global deaths) will occur in Africa in 2022. Across the continent, 1.27 billion people are at risk of malaria. Of these, 186 cases per 1,000 people and 47 deaths per 100,000 people will occur. Compared to 2000, these figures represent a 38% reduction in new cases and a 60% reduction in deaths. Over the past two decades, 1.6 billion cases and 10.6 million deaths have been reduced in Africa.
Climate change poses a major threat to health and malaria control gains. Warmer temperatures and increased precipitation will lead to increased malaria transmission. More frequent and intense natural disasters will destroy infrastructure and disperse populations. In 2023, Cyclone Freddy impacted southern Africa like never before. Thousands of health facilities were destroyed, populations were left unprotected from mosquito bites, and recovery services were washed away. Without urgent action, malaria cases and deaths and neglected tropical diseases will become more prevalent under climate change and health care.
Figure 2. Estimated number of malaria cases by country in 2023 |Source: WHO, 2024
PhD Tedros Ghebreyesus, Director‐General of WHO, said that in 2023, WHO has approved the priority use of insecticide‐treated bed nets.Pyrethroid‐chlorfenapyr. These are nets that contain two active ingredients at the same time (dual‐active ingredient nets) and are 43% more effective than nets impregnated with only one type. pyrethroidvand still maintains its effectiveness up to 40% at the end of the third year of use. At the same time, at the end of 2022, WHO will approve the drug Artesunate‐pyronaridine for the treatment of uncomplicated malaria in Africa and in October 2023, WHO recommended a second vaccine, R21/Matrix‐M, for the prevention of malaria caused by P. falciparum in children. Both the R21 vaccine and the previously approved RTS,S vaccine are safe and effective in preventing malaria in children. There is no evidence that one is superior to the other. The contribution of these two vaccines to the malaria toolkit and implementation and the measures already in place.
Figure 3. Malaria incidence in African countries |Nguồn: World Malaria Report 2024
In terms of insecticide resistance, 35 Member States have identified resistance to 3‐4 insecticides used for malaria control. Insecticide resistance reduces the effectiveness of the main vector control measures, insecticide treated bed nets and indoor residual spraying. Newer generation vector control methods are more effective and will have a greater impact but are more expensive.
Malaria mosquito An. stephensi has been detected in 8 member states Ethiopia, Eritrea, Djibouti, Ghana, Kenya, Nigeria, Sudan, Somalia. Unlike other malaria mosquitoes in Africa, the An. stephensi have invaded urban areas, where they breed and lay eggs in man‐made water channels, increasing the risk of urban malaria. Blood‐feeding behavior An. stephensi shows that indoor vector control measures such as insecticide‐treated bed nets are not effective and that resistance to many insecticides is increasing. In 2023, WHO updated its “Innovations to stop the spread of mosquito An. stephensi in Africa(Initiative to Stop the Spread of Anopheles stephensi in Africa).
Core priorities include increasing cooperation, strengthening insect surveillance, improving information systems exchange, and developing guidelines and research priorities. Countries should increase surveillance efforts and, where detected, implement mosquito control measures. An. stephensi as soon as possible
In addition, global partners Continued concern about drug resistance in malaria parasites, including partial resistance to artemisinin, and central resistance to the main component of artemisinin‐based combination therapies (ACTs) commonly used to treat malaria P. falciparumchưa biến chứng. Drug resistance delays parasite clearance in patients and reduces treatment effectiveness. WHO launches a Global Strategy to Respond to Drug Resistance in Africa (Global Strategy to Respond to Antimalarial Drug Resistance in Africa )with recommendations for what countries should do:
(1) Improved detection of drug resistance,
(2) Delay the emergence of drug resistance and
(3) Prevent the spread of drug‐resistant parasites. Member States are developing national strategies to monitor drug resistance and ensure appropriate use of diagnostics and treatment in line with national and global guidelines. All African countries are increasing surveillance to detect partial artemisinin resistance to guide new treatment.
Figure 4. Number of cases (blue line) and number of deaths (red line) in 11 African countries with the highest malaria burden and highest impact (High burden High Impact)
|Source: World Malaria Report, 2024
Deficiencies in rapid diagnostic tests (RDTs), despite the expansion of rapid diagnostic tests for health workers in diagnosing cases, especially at weak primary health care facilities. However, genetic mutations in malaria parasites have led to the loss of antigenic segments with specific detection targets. This increases the risk of missing many malaria patients.
To do this, member states are implementing surveillance systems to detect KSTSR with this mutation to change the more valuable rapid test.
High resources are critical to improving response and implementation of malaria surveillance interventions. National Malaria Programmes report gaps in management and implementation. Lack of laboratory technicians limits availability, accessibility and turnaround time for blood smears to malaria diagnosis.
Entomologists are under‐resourced for surveillance and early detection of insecticide resistance and the emergence of new vectors. Programmes often lack staff who actively support multi‐sectoral and cross‐border initiatives, and lack genuine researchers. Community health workers (CHWs) need to be recruited and trained. CHWs scale up malaria and other health services such as social and behavioural change communication and community case management at the community level.
CHWs are particularly important in diagnosing and treating malaria, reaching hard‐to‐reach areas, and strengthening pandemic preparedness.
Humanitarian crises are also a concern, with 41 malaria‐endemic countries affected by humanitarian crises between 2019 and 2022, resulting in displaced populations, displaced populations and unsafe environments. An estimated 169 million Africans are affected in 15 Member States in 2022. Sustained malaria‐related interventions throughout the humanitarian crisis are essential to prevent deaths.
Figure 6. Multi‐sectoral response model with effective health system components
National malaria control programmes report concerns about reduced access to health services and disruption of malaria prevention and control campaigns. Health services should be integrated into broader humanitarian crisis responses to ensure that National Malaria Control Programmes have easy access to affected populations and work with NGOs, international emergency organisations and other partners to design interventions and provide appropriate funding and procurement mechanisms.
The situation of malaria patients imported from Africa
From the beginning of 2024 Up to now, the Tropical Disease Centers ‐ Bach Mai Hospital, Dang Van Ngu Hospital ‐ Central Institute of Malaria ‐ Parasitology ‐ CT, Quy Nhon Institute of Malaria ‐ Parasitology ‐ CT, Central Hospital of Tropical Diseases, Ho Chi Minh City Hospital of Tropical Diseases, Tropical Disease Center ‐ Nghe An General Hospital, CDC Center of Nghe An Province, CDC Center of Ha Tinh Province, … have recorded examination and treatment for nearly 100 malaria patients with different species of malaria parasites, returning to Vietnam from African countries, the Mekong Sub‐region, the patients are mostly temporary workers or short‐term experts of corporations working here, or peacekeeping forces.
In particular, there are hospitalized patients who were misdiagnosed at the front line (including epidemiological exploitation in the areas where the patients returned, even though they were suffering from prolonged illness of unknown cause) or because they took unknown drugs bought from pharmacies and private health systems, which were ineffective or had low effectiveness (antibiotics or even quinine and chloroquine bought on the market), so when they were hospitalized, their illness progressed quite severely and threatened death when they were admitted to upper‐level medical facilities as mentioned.
Malaria is “imported” mostly from countries with high numbers of malaria patients in African countries such as Angola, South Sudan, Nigeria, Ivory Coast, Congo, Niger, … the number of years the patient has lived and worked there ranges from 1‐12 years, the patient can infected with many different species of malaria parasites includingP. falciparum, P. vivax, P. ovale. There are some cases of monogenic infection. P. malariae in Africa causing severe malaria as in patients with severe malaria due to P. malariaerecorded in Khanh Hoa, Vietnam in 2023‐2024. In addition, there were pregnant women who returned from Angola to work and contracted malaria and were hospitalized and treated in a condition that threatened both the mother and the fetus.
Current complications commonly encountered in cases of severe malaria in imported malaria patients returning from Africa and the Mekong Subregion include multi‐visceral or single‐visceral malignant malaria in the brain, hepatobiliary digestive system, acute renal failure, severe thrombocytopenia, acute pulmonary edema and progressive acute respiratory distress syndrome, splenomegaly with threat of splenic rupture, and severe anemia.
Because the disease progresses quite complicatedly due to late hospitalization or incorrect diagnosis and treatment at the front line, many patients are in critical condition, need multidisciplinary consultation, intensive resuscitation and expensive treatment costs for their families.
Although, over the past 5 years, Vietnam has been very successful in reducing morbidity and mortality and controlling malaria well under the participation and funding of the Government, NGOs and International Projects in Vietnam, so the malaria elimination roadmap has been quite successful, most of the remaining cases are mainly concentrated in the Central Highlands and especially malaria patients returning from countries with endemic disease, called non‐indigenous malaria cases or imported malaria cases, causing many challenges in control and prevention without the participation of inter‐sectoral agencies.
In clinical practice of infectious diseases, it seems that epidemiological factors are being “missed” or “forgotten”, making it easy to miss epidemiological factors related to malaria, which will delay diagnosis. In addition, control at airports, border gates and seaports, including traffic routes and informal trade, also needs to be noted and controlled as an infectious disease. Passengers returning to Vietnam from African or South American countries will often have to “transit” through countries in Europe, the Middle East, and Asia before arriving at Tan Son Nhat, Noi Bai, Cam Ranh, and Da Nang airports.
Therefore, in cases of fever, especially prolonged fever of unknown cause (Fever of unknown origin_FUO)and have an epidemiological history of travel from African and South American countries, the Mekong Sub‐region, clinicians and general health workers need to screen and prescribe malaria parasite testing (blood smears, rapid diagnostic tests and molecular biology if available) andneed health declaration with the authorities. The antimalarial drugs currently used in Vietnam are effective enough to treat malaria parasites in Africa and quickly kill the parasite mass within the first 24‐48 hours.
For many years now, many provinces and cities in the North and South have almost no domestic malaria patients, so they rarely face the image of malaria and gradually may not think of malaria from the beginning, so the timely detection, diagnosis and treatment of malaria cases returning from abroad at many lower‐level medical facilities are easily missed or delayed. Therefore, the above information will be a warning about the large number of imported malaria cases and can lead to malignant malaria or death if not paying attention and being vigilant.
Furthermore, most of the workers returning from Africa have their household registration in rural or mountainous areas, where malaria was once endemic, and now malaria mosquitoes may still exist, so if just a few cases carrying malaria parasites return and have disease vectors available, the risk of spreading and outbreaks will be inevitable!
è(Continued Part 2)
