2015 WORLD MALARIA REPORT MARKS END OF MILLENNIUM DEVELOPMENT GOALS ERA
In her forward to the 2015 World Malaria Report (WMR), World Health Organization (WHO) Director General Dr. Margaret Chan neatly summarized our progress toward the malaria-related Millennium Development Goals (MDG), established in 2000. To paraphrase, we’ve come a long way but we still have a long, long way to go.
In virtually every strategic area and most regional settings, WMR 2015 shines a light on our significant progress in controlling the world’s most deadly vector-borne disease. At the same time, projections indicate that funding must increase by nearly 350% if the new malaria reduction Sustainable Development Goal (SDG) of 90% between 2016 and 2030 is to be accomplished. Following is a brief summary of incidence data, interventions, and future challenges taken from WMR 2015.
INCIDENCE AND MORTALITY PROGRESS
Globally, the number of estimated malaria cases fell from 262 million in 2000 to 214 million in 2015, an absolute decline of 18%. The incidence of malaria, which takes into account population growth, pushes that figure to an estimated 37% decline in malaria cases between 2000 and 2015.
The global malaria mortality rate, which also takes into account population growth, is estimated to have decreased by 60% over the same period. In 2015, malaria was responsible for an estimated 438,000 deaths, whereas an estimated 655,000 malaria deaths occurred as recently as 2010. Every WHO region showed significant progress in both incidence and mortality rates in the MDG era (see Graph 1). While only 13 countries were estimated to have fewer than 1,000 malaria cases in 2000, that number rose to 33 by 2015.
MALARIA INCIDENCE AND DEATH RATE REDUCTION
Millennium Development Goal 6C called for a reversal of the incidence of malaria (and other major diseases)
around the world by 2015. Data from WMR 2015 demonstrates how that goal was achieved, as regional
incidence rate declines ranged from 42% to 100%.
Graph 1: Estimated Malaria Incidence and Death Rates by WHO Region, 2000–2015
From a regional perspective, the European region celebrated reporting zero indigenous cases of malaria for the first time since WHO started tracking. In 2014, 16 countries reported zero indigenous cases of malaria for the first time since WHO started tracking. In 2014, 16 countries reported zero indigenous cases (Argentina, Armenia, Azerbaijan, Costa Rica, Iraq, Georgia, Kyrgyzstan, Morocco, Oman, Paraguay, Sri Lanka, Tajikistan, Turkey, Turkmenistan, United Arab Emirates, and Uzbekistan). Three more countries and territories reported fewer than 10 indigenous malaria cases (Algeria, El Salvador and Mayotte [France]). All told, 57 of 106 countries that had ongoing transmission in 2000 reduced malaria incidence by more than 75% between 2000 and 2015. Another 18 countries are estimated to have reduced malaria incidence by 50–75%.
Africa continues to be the most challenging region. An estimated 88% of malaria cases in 2015 occurred in the WHO African region and 15 countries, mainly in Africa, account for nearly 80% of the world’s malaria deaths (see Graph 2). However, the region has seen impressive gains, with malaria mortality rates having fallen by 66% among all age groups and by 71% among children under five years of age. Once the leading cause of death among children in sub-Saharan Africa, the disease now ranks fourth.
AFRICA MALARIA BURDEN
Graph 2: 2015 Countries with Highest Share of Malaria Burden
On a global scale, pursuant to the MDG 4 target of reducing the global mortality rate for children under five years of age by two-thirds by 2015, the number of malaria deaths is estimated to have decreased from 723,000 to 306,000 in 2015 (58%). About 3.2 billion people remain at risk of malaria.
“It is estimated that a cumulative 1.2 billion fewer malaria cases and 6.2 million fewer malaria deaths occurred globally between 2001 and 2015 than would have been the case had incidence and mortality rates remained unchanged since 2000.”
– WORLD MALARIA REPORT
INTERVENTIONS
In addition to incidence and mortality rates between 2000 and 2014, reductions in malaria cases are estimated to have saved about US$900 million on case management costs in sub-Saharan Africa alone. Progress is attributable to the collective rollout of prevention and treatment tools, namely insecticide treated nets (ITNs), indoor residual sprays (IRS), expansion in diagnostic testing, and the availability of antimalarial medicines. In recent years, the number of countries employing Larval Source Management (LSM) strategies has also increased dramatically (see “Trending Now”).
Despite the gains in malaria intervention coverage, WMR 2015 indicates that millions of people still don’t receive the services they need. Funding is the major cause. The report estimates that in sub-Saharan Africa in 2014, 269 million people at risk of malaria lived in households without ITN or IRS, 15 million pregnant women at risk did not receive a single dose of antimalarial medicine, and between 68 and 80 million of the 92 million children afflicted with malaria did not receive artemisinin-based combination therapies (ACTs).
ONGOING CHALLENGES
WMR 2015 makes clear that malaria control program financing remains a significant challenge, one closely tied to slower declines of malaria in high-burden countries. Of all the money in the WHO African Region in 2014, only 9% came from domestic funding. By contrast, of the US$1.9 billion contributed by international sources on a global scale, 82% (US$1.56 billion) was directed to the WHO African region.
As a positive trend, global financing for malaria control increased from an estimated US$960 million in 2005 to US$2.5 billion in 2014. As a negative trend, international funding decreased slightly from US$2.1 billion in 2013 to US$1.9 billion in 2014, at a time when funding remains a barrier to reduction goals.
Insecticide resistance continues to dominate the landscape of operational challenges. ITN and IRS efficacy remains severely challenged by malaria mosquitoes developing resistance to the insecticides on which those interventions are based. WMR 2015 states that of the 78 countries reporting monitoring data in 2010, 60 (77%) reported resistance to at least one insecticide in one vector population. Another 49 countries (63%) reported resistance to insecticides from two or more mode of action classes.
Most prominent among these resistance challenges are pyrethroids, upon which current chemical interventions heavily rely. Since the vast majority of ITNs and IRS interventions are based on pyrethroids, the significant gains achieved to date are at risk—as is future success. More worrisome is that despite the huge investments in— and reliance on—ITNs and IRS, many countries don’t conduct routine malaria vector surveillance, including surveillance for insecticide resistance. Among the nearly 100 countries reporting the adoption of vector control policies that include ITNs or IRS, only 52 reported resistance data for 2014.
TOWARD THE FUTURE
To address these and other challenges, WHO has developed a Global Technical Strategy for Malaria 2016–2030. The strategy was developed in close alignment with the SDGs and Roll Back Malaria RBM Partnership’s Action and investment to defeat malaria 2016–2030—for a malaria free world. Adopted by the World Health Assembly in May 2015, the Global Technical Strategy has three core pillars. The first is to ensure universal access to malaria prevention, diagnosis, and treatment. The second is to accelerate efforts toward elimination of malaria and attainment of malaria-free status. The third is to transform malaria surveillance into a core intervention.
Again, funding will figure prominently in success. WMR 2015 indicates that annual investments in malaria control will need to increase to an estimated US$6.4 billion per year by 2020 to meet the first milestone of a 40% reduction in malaria incidence and mortality rates. Annual investments must then rise to US$7.7 billion by 2025 in order to meet the second milestone of a 75% reduction. To achieve the 90% reduction goal, annual malaria spending will have to reach an estimated US$8.7 billion by 2030.