MANUEL HETZEL
LOCAL newspapers in Papua New Guinea recently reported the good news that the country was making progress in the fight against malaria.
And indeed, PNG has made immense progress in the fight against the deadly scourge.
Since the resuscitation of the National Malaria Control Program in 2008 with money from the Global Fund to Fight AIDS, Tuberculosis and Malaria, malaria cases have continuously decreased.
The distribution of long-lasting insecticidal nets and the introduction of the new and highly effective artemisinin-based combination treatment have changed the malaria landscape in PNG once again.
In malaria surveillance sites established by the PNG Institute of Medical Research (IMR), the incidence of malaria dropped from 205 cases per 1000 people in 2009 to 48 cases per 1000 in 2014.
Extrapolated to the entire country, this translates to 35,000 malaria cases less – every year! Over the same period, the Health Department reported a 50% reduction in malaria deaths.
Never since the global eradication efforts in the 1960–70s has the country achieved a comparable reduction in the malaria burden. Never since that time was so much money and concerted effort invested in controlling malaria.
The current success was possible because $US120 million were provided between 2009 and 2014 to the Health Department, Rotarians Against Malaria, Population Services International, Oil Search Health Foundation and their partners to implement a comprehensive and well-designed malaria control program.
It has been so successful that, in some areas of the country, malaria has almost disappeared.
The PNG IMR surveillance site in Balimo finds hardly any cases and even in Arawa, Bougainville, malaria patients in the health centre have become a rarer sight.
Household surveys in South and Middle Fly, Central Province and Port Moresby detected hardly any people infected with malaria parasites. And in the Maprik area of East Sepik, a place infamous for its high malaria burden, there is not enough malaria left to carry out most malaria research.
Nevertheless, it is not the time to sit back and relax. In the 1980s, the cessation of the malaria eradication program and the increase in antimalarial drug resistance (to chloroquine and sulphadoxine-pyrimethamine or fansidar) led to a massive resurgence of malaria cases in PNG. The same was seen in malarious countries around the world.
One of the reasons for these rebounds are so-called sub-patent malaria infections – infections with a very low number of parasites that remain undetected by normal diagnostic methods such as microscopy or rapid diagnostic tests.
The IMR is currently analysing blood samples from across PNG with modern molecular techniques and it is evident that despite the drop in malaria, many people remain infected with a very low number of malaria parasites. These are often sufficient to infect mosquitoes and sustain the transmission cycle.
If control efforts decrease, human-mosquito contacts will increase and mosquitoes will again be able to pass on the parasites. The under-cover human reservoir will then fuel the next big epidemic.
In October this year, the current grant from the Global Fund came to an end and negotiations for a continuation are still in progress. Something is already certain: the coming grant will only be a fraction of the previous five-year support.
At the same time, the World Health Organisation’s World Malaria Report 2014 presents the fact the virtually none of the current funding for malaria control activities comes from domestic resources (that is, the government).
If PNG wants to avoid repeating the experiences following the 1980s, the funding commitment from the government needs to increase substantially or other donors need to be found. The biggest mistake at this point would be to argue that less funding is required as the burden has decreased. The opposite is the case.
Of course, the available resources are limited but a life of a malaria-sick child should not be worth less than the life of any other sick child. And studies from many places have already demonstrated that malaria control is a low hanging fruit; and mosquito nets are one of the most cost-effective public health interventions.
The challenge is therefore to sustain adequate funding for the malaria program to continue with the successful interventions. Political support and support from the people affected is critical. Far too often are people indifferent to the dangers of malaria.
The partnership of different organizations with different expertise and experience has been fruitful. And recent private sector initiatives may usefully complement the efforts. However, they need to follow the same strategy or else they risk undermining the overall efforts.
Advertising impregnated beer cartons for malaria control may be a funny marketing trick but should not be an example for others to follow.
Last but not least, there is the need for data to support decision making. Valid and accurate data helps the program implementers to fine-tune the interventions and “sell” their successes to local decision-makers and foreign donors. Collecting such data needs money and scientific expertise.
The good news about malaria that is spread in the papers these days is based largely on studies and surveillance data from the PNG Institute of Medical Research conducted on behalf of the National Department of Health. Hopefully it will be used by those in power to make the right decisions.
Manuel Hetzel PhD is scientific project leader of the Swiss Tropical Institute