Today is World Malaria Day. Dr Waqo Ejersa, head of the National Malaria Control Programme, explains to our writer what Kenya is doing to join Europe and other regions that have eliminated the killer disease.
According to the World Malaria Report 2015, there were 214 million cases of malaria globally in 2015 (uncertainty range 149–303 million) and 438 000 malaria deaths (range 236 000–635 000), representing a decrease in malaria cases and deaths of 37 per cent and 60 per cent since 2000, respectively. The burden was heaviest in the World Health Organisation African Region, where an estimated 90 per cent of all malaria deaths occurred, and in children aged under 5 years, who accounted for more than two thirds of all deaths
In Kenya, the malaria prevalence is reducing every year. About five years ago, 30 to 40 per cent of all outpatients in hospitals were malaria patients but now that has reduced to just over 10 per cent. A new vaccine candidate Mosquirix has been approved on a global level and Kenya been accepted as one of the African countries where a pilot programme will be carried out.
How is the current situation of malaria in the country?
We have fought malaria for many years and are winning the battle, but it is still a great concern. If unchecked, it can be detrimental to the lives of children under five, pregnant women, farmers and students, making it a developmental issue.
Year by year, the malaria prevalence is going down. As a whole, the prevalence in 2010 was 11 per cent nationally but it came down to eight per cent by last year. In the bulk of this country, it is less than one per cent.
This is largely due to aggressive investments by the state and our development partners like the US and the UK. In central highlands and semi-arid areas, the prevalence is so low, we are tempted to declare pre-elimination phase. But we have to work as a country, so we are liaising with counties in the Coastal strip and the Lake Victoria region before we declare. People should sleep under the long-lasting insecticide treated nets (LLINs), or simply mosquito nets, every night, whether in dry or wet weather.
97 per cent of public and faith-based health facilities can now comfortably diagnose malaria through rapid diagnostic tests or microscopy. So anyone having fever symptoms can be tested and treated quickly. All our facilities have enough stocks of the right anti-malarial, the Artemether Lumefantrine (sold under the trade name Coartem). Everybody getting fever should be tested and treated quickly, because
Western Kenya has a high rate of 27 per cent, yet in most of the country, the prevalence is one per cent? Why?
In areas around the lake and near the border, there are high rates of malaria in neighbouring countries so cross-border transmission is high. Nevertheless, measures we have undertaken are working. Ten years ago, we had 60 to 80 per cent prevalence in the Lake Victoria endemic region, where transmission occurs throughout the year irrespective of the season. It came down to 37 to 40 per cent in 2010. Now we are talking of 27 per cent.
Could cross-border transmission defeat local efforts to fight the disease?
We share a lot of notes as the East African Community. Uganda is investing in the same tools and style as Kenya to fight malaria. It is a peaceful country and its health systems work well. Through our combined efforts, everything will work well. That's probably why we even reduced prevalence from 37 to 27 per cent in Kenya.
What tools are being used to reduce prevalence?
One is the use of mosquito nets. We used to treat them every six months, but the treatment now lasts three years. We have achieved national coverage, meaning there's one net for every two Kenyans. The other method is preventing infections in vulnerable groups like children under one, whom we give nets to, and pregnant women, who get nets and SP (Fansidar), the medicine that prevents transmission of malaria to the unborn.
There's also indoor residue spraying. We haven't done this so much because it's a very expensive venture. Another measure is aggressive case management. Sorting out fevers promptly and effectively which should be done within 24 hours of onset ensuring it is treated with the most efficacious drug.
Why is it so important to treat fever quickly?
Once you realise it's cause is a malaria parasite, you should fight that parasite with an anti-malarial. That means you're cleaning up the reservoir. What a mosquito does is transmit malaria from me to you. So if I have the parasite and take those medicines right away, the mosquito will bite me but it will not find any parasite to transmit to you. This method also acts as preventive strategy.
The DDT is probably the most effective pesticide recommended by the WHO for residual spraying. Do we use it in Kenya?
No, we don't. DDT (dichloro-diphenyl-trichloroethane) was used many years back but it had some undesired side-effects. So we moved to using pyrethroids. They were very effective when used in indoor spraying where we spray walls and materials in houses especially bedrooms. But these mosquitoes developed resistance to the pyrethroids. So we now use Actellic 300CS (a pesticide made by Sygenta), which has proven to be very effective and there's no resistance yet. The nets are still treated with pyrethroids, so we have a different chemical for the nets and a different chemical for the walls.
How much do we spend on malaria control?
We need Sh54 billion in three years to fight malaria. So far, we have about half that amount — Sh27 billion — so there is a 50 per cent gap in budget. The funding comes from donors like the Global Fund, US President Malaria Initiative and the UK's Department for International Development.
Are there any notable ongoing research studies on mosquito control?
There are a lot of studies on entomological surveillance, investigating the level of mosquito resistance to the chemicals we use on nets and walls. There are also studies on the behaviour of mosquitoes. Sometimes, they bite outdoors, and other times, indoors. This keeps changing so we might be focusing on providing nets, when they could be biting outside. So we monitor the behaviour very carefully working closely with the Kenya Medical Research Institute (Kemri), the Centre for Disease Control (CDC) and the Kemri-Wellcome Trust.
What's the progress on finding a malaria vaccine for children?
The malaria community is continually looking for new tools. One is the malaria vaccine, where we have had many trials. Fortunately, one called Mosquirix has passed through the phase three trial. It has gone through various steps, including the European Medicines Agency, which has given it a positive scientific note, saying it's safe, efficacious and can save children's lives. WHO also looked at the vaccine and two of its advisory committees — the Strategical Advisory Group of Experts on Immunisation and the Malaria Policy Advocacy Committee — approved it. WHO has advised us that we need to do a pilot implementation of the vaccine. They will look for about three to five African countries to see how the vaccine can fit into their immunisation programmes.
Kenya applied and I am happy to report that WHO has accepted our application to be one of the countries in the pilot implementation. We are now waiting for WHO to get funding to start the programme. Most probably, it won't be the whole country. We will have to start with the Lake Victoria endemic region, where malaria is very high and there is an urgent need to protect the children.
This Malaria vaccine is targeting children of between five and 17 months and we are hoping that it proves to be very effective.
There is evidence that malaria can be eliminated in diverse geopolitical zones, including sub-Saharan Africa. What would you say of Kenya?
Our vision is a malaria-free Kenya. It may not happen within a year but we have fixed our vision to have it eradicated. I'm sure we'll finish malaria in this country in our lifetime.
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