First of its Kind Comprehensive Assessment of Malaria in Madagascar Paves Way for National Strategic Plan for its Eradication

Researchers at the Center for Global Health & Diseases at Case Western Reserve University School of Medicine, and international colleagues, have provided the first of its kind comprehensive assessment of the current status of malaria in Madagascar, laying the groundwork for the 2018-2022 national strategic plan for eliminating malaria in the island nation off the southeast coast of Africa.

“Our approach is easily applied to other countries attempting to eliminate malaria because it uses detailed data from Madagascar’s national health management information system to assess the monthly incidence of the disease,” said Peter A. Zimmerman, Ph.D., a senior author of the study. “Mapping malaria transmission in this way provides a systematically updated framework that can make an enormous difference helping governments make policies to establish successful strategies to eliminate malaria from their countries.”

Peter A. Zimmerman, PhD, professor of international health, the Madagascar National Malaria Control Program, and the Malaria Atlas Project at Oxford University have conducted a comprehensive analysis of routine malaria data gathered by the Ministry of Health in Madagascar. The resulting research article is published online this month in Malaria Journal.

“By evaluating malaria incidence data from all 112 health districts across Madagascar, this collaboration provides a consistent assessment of malaria throughout the country over the past six years,” said Zimmerman. “The practical utility of this study is to help develop the country's national strategic plan for malaria elimination. Additionally, this collaboration provides a framework for Madagascar to monitor and assess ongoing malaria transmission and its efforts at malaria reduction.”

Malaria is a potentially life-threatening blood disease caused by parasites transmitted through bites from the Anopheles mosquito. Symptoms include chills, headache, muscle ache, fatigue, nausea, vomiting, and diarrhea. If untreated, coma and death may result.

The assessment found that the prevalence of malaria is highly diverse across the island’s ecological regions, with east and west coastal areas showing the highest transmission year-round, contrasting with the central highlands and desert south where trends appear more closely associated with periodic epidemic outbreaks. Nationwide, there has been a steady increase in reported malaria cases since 2010, with a near doubling of raw reported case numbers from 2014 to 2015. Zimmerman says that the raw reported case numbers significantly underestimate the true caseload, since only about 60–75 percent of health facility data (from 3,924 health facilities) are reported to the national health ministry each month.

The assessment includes detailed graphs illustrating seasonal variations in malaria transmission in eight geographical sub–units of the country. “The sometimes striking differences are a result of varying socio-economic, climatological, and ecological conditions across the various regions of Madagascar,” said Zimmerman. “Therefore, no single approach for malaria control is likely to be successful when applied across the island. Rather, it is crucial for a sub-national perspective to be employed when assessing local control needs and providing appropriate prevention and treatment.”

Zimmerman and one of the study’s co-authors, Rosalind Howes, DPhil, of the Malaria Atlas Project at Oxford University, have been invited to participate in a meeting in late November to set the agenda for Madagascar's 2018-2022 national malaria strategic plan and malaria elimination campaign. Arsene Ratsimbasoa, MD, PhD, another co-author, is Director of the Madagascar National Malaria Control Program and will be charged with carrying out the new strategic plan.

Malaria remains a major public health problem in Madagascar. Widespread scale-up of intervention coverage has led to substantial reductions in case numbers since 2000. However, political instability, triggered by a political coup in 2009, has disrupted these efforts, including impeding inflows of international funding, and a resurgence of malaria has subsequently occurred. “The situation in Madagascar is consistent with what has been widely reported from other areas, namely, withdrawal of crucial core funding is closely associated with rapid and predictable resurgence of malaria,” said Zimmerman.

Madagascar has the seventh lowest per capita gross domestic product in the world, with at least three/fourths of the population living under the national poverty line. The population is predominantly rural (66 percent), and almost half (42.4 percent) is younger than 15 years. Malnutrition is rampant, affecting over half of children, with 25 percent of children reported to be severely malnourished. Malnutrition increases susceptibility to infections such as malaria. In the five to 14 years age bracket, uncomplicated malaria represented the second-most common cause of health center consultations in 2012, while complicated malaria was the top cause of hospital deaths, at 10.1 percent overall, and 21.6 percent among children under the age of five. Zimmerman and his colleagues report that all 23.9 million people in Madagascar are at risk of malaria exposure.


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