malaria 2010 who

7/21/2019 malaria 2010 who

1/93

W O RLD

M ALARIA

REPO RT

2010

Please see the Table of Contents for access to the entire publication.

7/21/2019 malaria 2010 who

2/93

W O RLD M ALARIA REPO RT

2010

WHO Global Malaria Programme

7/21/2019 malaria 2010 who

3/93

World Health Organization 2010

All rights reserved. Publications of the World Health Organization can be obtained f rom WHO Press, World Health Organization, 20 avenue Appia,

1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce

or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address

(fax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on

the part of the World Health Organization concerning the legal status of any country, terr itory, city or area or of its authorities, or concerning

the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full

agreement.

The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World

Health Organization in preference to others of a s imilar nature that are not mentioned. Errors and omissions excepted, the names of proprietary

products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to ver ify the information contained in this publication. However,the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation

and use of the mater ial lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Photo on cover: Adapted from John Stanmeyer/VII

WHO Library Cataloguing-in-Publication Data

World malaria report : 2010.

1.Malaria - prevention and control. 2 Malaria - economics. 3.Malaria - epidemiology. 4.Disease vectors. 5.Insecticide-treated bednets.6.Antimalarials. 7.Drug resistance. 8.Case management - administration and organization. 9.World health. I.World Health Organization.

ISBN 978 92 4 156410 6 (NLM classification: WC 765)

7/21/2019 malaria 2010 who

4/93

ContentsStatement by the United Nations Secretary-General ................................................................................................................................................v

Foreword: Director-General World Health Organization .......................................................................................................................................vii

Acknowledgements .........................................................................................................................................................................................................................viii

Abbreviations ......................................................................................................................................................................................................................................... ixSummary ................................................................................................................................................................................................................................................. xi

Key points .............................................................................................................................................................................................................................................xiii

1. Introduction ...............................................................................................................................................................................................................................1

2. Goals, policies and strategies for malaria control and elimination ..................................................................................3

2.1 Goals and targets for malaria control and elimination .............................................................................................................3

2.2 Malaria control policies and strategies ...................................................................................................................................................4

2.3 Malaria elimination ...................................................................................................................................................................................................6

2.4 Indicators ..........................................................................................................................................................................................................................7

3. Financing malaria control .........................................................................................................................................................................................11 3.1 Resource requirements ........................................................................................................................................................................................11

3.2 International financing of malaria control .......................................................................................................................................11

3.3 Domestic financing of malaria control.................................................................................................................................................. 12

3.4 Category of expenditure by source of funds.................................................................................................................................... 13

3.5 Disbursements by country ...............................................................................................................................................................................14

3.6 Disbursements by stage of malaria control ......................................................................................................................................14

3.7 Conclusions ...................................................................................................................................................................................................................15

4. Vector control ........................................................................................................................................................................................................................17

4.1 ITN policy and implementation ..................................................................................................................................................................17

4.2 IRS policy and implementation ...................................................................................................................................................................23

4.3 Conclusions ...................................................................................................................................................................................................................24

5. Malaria diagnosis and treatment .......................................................................................................................................................................25

5.1 Diagnosis of malaria.............................................................................................................................................................................................. 25

5.2 Treatment of malaria ............................................................................................................................................................................................28

5.3 Intermittent preventive treatment ..........................................................................................................................................................33

5.4 Antimalarial drug resistance .........................................................................................................................................................................34

5.5 Conclusions ...................................................................................................................................................................................................................36

6. Impact of malaria control .........................................................................................................................................................................................39

6.1 Assessing the impact of malaria interventions ............................................................................................................................39 6.2 African Region: high-burden countries................................................................................................................................................ 40

6.3 African Region: low-transmission countries ....................................................................................................................................46

6.4 Region of the Americas ......................................................................................................................................................................................48

6.5 South-East Asia Region ......................................................................................................................................................................................50

6.6 European Region .......................................................................................................................................................................................................52

6.7 Eastern Mediterranean Region .....................................................................................................................................................................54

6.8 Western Pacific Region .......................................................................................................................................................................................56

6.9 Malaria elimination and prevention of reintroduction ...........................................................................................................58

6.10 Global estimates of malaria cases and deaths, 20002009 ...............................................................................................58 6.11 Conclusions ...................................................................................................................................................................................................................60

PROFILES 24 high-burden countries .........................................................................................................................................................................63

ANNEXES ........................................................................................................................................................................................................................................... 137

Please click below to access the different chapters within.

7/21/2019 malaria 2010 who

5/93

7/21/2019 malaria 2010 who

6/93W O RLD M ALARIA REPO RT 2010 v

7/21/2019 malaria 2010 who

7/93

7/21/2019 malaria 2010 who

8/93W O RLD M ALARIA REPO RT 2010 vii

Foreword

Dr Margaret Chan,Director-General World Health Organization

The findings in the World Malaria Report 2010further

strengthen the business case for investing in malaria control.The accelerated drive to achieve universal coverage withtodays tools, called for by the United Nations Secretary-General in 2008, continues to produce results. Nearly 289million insecticide-treated mosquito nets (ITNs) will havebeen delivered to sub-Saharan Africa between 2008 and2010, enough to protect 578 million people. In Africa, 75million people, or 10% of the population at risk, were alsoprotected in 2009 by indoor residual spraying. These arereal achievements.

These prevention efforts are producing a measurablepublic health impact. The annual number of malaria casesand deaths continues to decline, especially in Africa. Thenumber of countries that have successfully cut their malariaburden in half over the past decade continues to rise. Forthe first time, not a single case of falciparum malaria wasreported in the WHO European Region in 2009. One by one,we are counting down the number of countries endemicfor malaria. This year alone, I had the honour to certify bothMorocco and Turkmenistan as being free from malaria, andwas able to add the names of these countries to the Officialregister of areas where malaria elimination has been achieved.

Major changes in the way we tackle malaria areoccurring quickly. This is the year when we finally declaredthat everyone with suspected malaria has a right to aconfirmatory diagnostic test. The time for this change wasoverdue. For too long in too many places, fever has beenequated with malaria. No more. Our efforts at preventionhave produced real changes in malaria transmission,and most cases of fever, even in Africa, are no longer dueto malaria. This is another clear marker of progress, and

another sign of the way control strategies are constantlybeing refined. We have inexpensive, quality-assured rapiddiagnostic tests that can be used all the way down to thecommunity level.

In 2009, more than a third of suspected malaria casesreported in Africa were confirmed with a diagnostic test,a dramatic increase from the less than 5% at the beginningof the decade. A small number of African countries have

been able to rapidly scale up malaria diagnostic testingat a national level. Not only has this resulted in saving theunnecessary use of hundreds of thousands of courses ofACTs annually, but has also allowed for the implementationof timely and accurate surveillance for malaria. This is a greatleap forward. Only by knowing where our enemy lurks,identifying the places where we still have malaria, can weexpect to defeat it.

While there is much to celebrate, the data in this reportalso underscore the fragility of our progress. Resurgencesof malaria were observed in parts of at least three Africancountries. The exact reasons for these sharp increases arenot known, but likely reect some combination of naturalvariation and lapses in control measures. These programmefailures are a pointed reminder of what could happen ifwe reduce our vigilance and do not follow through onour collective commitments. In many ways, sustaining thehigh coverage rates with malaria prevention and controlmeasures may prove even more challenging than havingachieved such coverage in the first place.

We cannot let this momentum slip. Significant recent

gains, though fragile, must be sustained. The internationalcommunity needs to ensure sufficient and predictableglobal funding to meet ambitious targets set for malariacontrol as part of the drive to reach the health-related

Millennium Development Goals by 2015.

The will to sustain the gains that we have made in malariamust come not only from global health leaders and frompoliticians, but from affected communities. If communitiescan know the true burden of malaria, and can see the resultsof prevention and control efforts, then the will to eliminate

and ultimately eradicate malaria will never fade.

7/21/2019 malaria 2010 who

9/93viii W O RLD M ALARIA REPO RT 2010

AcknowledgementsNumerous people contributed to the production of the World Malaria

Report 2010. The following collected and reviewed data from malaria

endemic countries: Ahmad Walid Sediqi (Afghanistan); Yava Ricardo (Angola);

Ara Keshishyan (Armenia); Viktor Gasimov (Azerbaijan); Mohammad Jahirul

Karim (Bangladesh); Kim Bautista (Belize); Yacoubou Imorou Karimou

(Benin); Thinley Yongzom (Bhutan); Marcos Ysrael Fernandez Encinas

(Bolivia (Plurinational State of)); Simon Chihanga (Botswana); Oscar

Mesones Lapouble (Brazil); Patrice Combary (Burkina Faso); Mbanye Hypax

(Burundi); Duong Socheat (Cambodia); Clestin Kouambeng (Cameroon);

Antonio Lima Moreira (Cape Verde); M'bary Siolo Mada Bebelou (Central

African Republic); Moussa Abba Mahamat (Chad); Xia Zhi-Gui (China);

Pablo E Chaparro N (Colombia); Amina Yssouf (Comoros); Jean Claude Batia

(Congo); Jos Luis Garcs Fernandez (Costa Rica); San Koffi Mose (Cte

D'ivoire); Benjamin Atua, Kalindula, Baseane (Democratic Republic of The

Congo); David Joa Espinal (Dominican Republic); Kim Yun Chol (Democratic

People's Republic Of Korea); Johanes Don Bosco (Democratic Republic Of

Timor-Leste); Enrique Castro Saavedra (Ecuador); Gloria Nseng Nchama(Equatorial Guinea); Tewolde G/Meskel (Eritrea); Worku Bekele (Ethiopia)

National Malaria Control Programme (French Guiana); J. Solange Antimi

(Gabon) Momodou Kalleh (Gambia); Merab Iosava (Georgia); Kofi Osae

(Ghana); Ilse Gongora (Guatemala); Amadou Sadio Diallo (Guinea); Duarte

Falco (Guinea-Bissau); Karanchand Krishnallal (Guyana); National Malaria

Control Programme (Haiti); Martin Ivan Sinclair (Honduras); GS Sonal

(India); Desak Made Wismarini, Mkes (Indonesia); Leila Faraji, Ahmad Raeisi

(Iran (Islamic Republic of)); Muthana Ibrahim (Iraq); National Malaria Control

Programme (Kenya); Nurbolot Usenbayev (Kyrgyzstan); Kongxay Luang-

phengsouk (Lao Peoples Democratic Republic) Tolbert Geewleh Nyenswah

(Liberia); Andry Joeliarijaona Rakotorahalahy (Madagascar); Misheck Luhanga

(Malawi); Christina Rundi (Malaysia); Klenon Traor (Mali); Ba Mamadou

Dit Dialaw (Mauritania); Hctor Olgun Bernal (Mexico); Samuel Jose Alves

Mabunda (Mozambique); Khin Mon Mon (Myanmar); P. Uusiku Uupindi

(Namibia); GD Thakur (Nepal); Rolando Francisco Lopez Ampie (Nicaragua);

Maazou Abani (Niger); EBA Coker (Nigeria); Muhammad Suleman Memon

(Pakistan); Raul Medina (Panama); Leo Sora Makita (Papua New Guinea);

Blanca Cousio, Cynthia Viveros, Beatriz Espinola (Paraguay); Mario

Baquilod (Philippines); Division Of Communicable Disease Control (Republic

of Korea); Alla Baranova (Russian Federation); Corine Karema (Rwanda);

Herodes S. Rompo (Sao Tome and Principe); Mohammed Alzahrani (Saudi

Arabia); Mame Birame Diouf (Senegal); Musa Sillah-Kanu (Sierra Leone);

Boaz Leornard (Solomon Islands); Fahmi E. Yusuf (Somalia); E Misiani, B

Shandukani, Ma Groepe (South Africa); S. L. Deniyage (Sri Lanka); Abd

Alla Ahmed Ibrahim Mohd (Sudan (North)); Robert Gama Hassan (Sudan

(South)); Simon P. Kunene (Swaziland); Tagaikulov Boturkhon (Tajikistan);

Saowanit Vijaykadga (Thailand); Liy Ayo (Togo); Seher Topluoglu (Turkey);Sofia Aliyeva (Turkmenistan); Ebony Quinto (Uganda); Frank Chacky (United

Republic of Tanzania (Mainland)); Abdullah Ali, Abdul-Wahid Al-Mafazy

(United Republic of Tanzania (Zanzibar)); Tyo Inna, Lebedeva Natalya,

Umarova P.H., Khusainova N. (Uzbekistan); George Taleo (Vanuatu); Nguyen

Quang Thieu (Viet Nam); Adel Nasser Aljasari (Yemen); Freddie Masaninga;

Mercy Mwanza (Zambia); National Malaria Control Programme (Zimbabwe);

Jean Bosco Ahoranyezu (WHO/Rwanda); Henok Kebede Ejigu (WHO/

Ethiopia); Derege Olana (WHO/Ethiopia); Rachel Eersel (WHO/Suriname);

Gustavo Bretas (WHO/Ecuador); Aida Soto (WHO/Nicaragua); Antonieta

Arias (WHO/Paraguay); Marco Fidel Suarez (WHO/Bolivia); Abdur Rashid

(WHO/Cambodia); Xiaodong Zhang (WHO/China); Deyer Gopinath (WHO/

LaoPDR); Harpal Singh (WHO/Malaysia); Zaixing Zhang (WHO/Papua New

Guinea); Jeffrey Hii (WHO/Philippines); Jeunessa Sto Nino (WHO/Philip-

pines); Larbi Kwabena (WHO/Solomon Islands); Walter Kazadi Mulombo

(WHO/Solomon Islands); Nam Hee Chung (WHO/Republic of Korea); Lasse

Vestergaard (WHO/Vanuatu); Dai Tran Cong (WHO/Viet Nam).

The following WHO staff in regional and subregional offices assisted in

the design of data collection forms, the collection and validation of data,

reviewed epidemiological estimates and country profiles, and prepared

country vignettes: Nathan Bakyaita (AFRO); Etienne Magloire Minkoulou

(AFRO); Georges Alfred Ki-Zerbo (AFRO); Amadou Bailo Diallo (AFRO/central

IST); Khoti Gausi (AFRO/eastern and southern Inter-Country Support Team,

ICST); Samson Katikiti (AFRO/ eastern and southern ICST); Abderrahmane

Kharchi (AFRO/western IST); Jean-Olivier Guintran (AFRO/western IST);

Rainier Escalada (AMRO); Prabjhat Singh (AMRO); Keith Carter (AMRO);

Ghasem Zamani (EMRO); Amir Aman (EMRO/DCD/MCE); Hoda Atta

(EMRO); Elkhan Gasimov (EURO); Karen Takse-Vester (EURO); Mikhail

Ejov (EURO); Rakesh Rastogi (SEARO); Krongthong Thimasarn (SEARO);

Bayo Fatunmbi (WPRO); Raymond Mendoza (WPRO) and Eva-Maria Chris-

tophel (WPRO).

Joshua Yukich of Tulane University undertook data analysis and prepared

text for Chapter 3 on malaria financing. Manoj Menon of the US Centers for

Disease Control undertook analysis of household survey data on ITN coveragein Chapter 4 on vector control. Abraham Flaxman, Nancy Fullman and

Stephen Lim at the Institute of Health Metrics and Evaluation, University of

Washington (USA) produced estimates of ITN coverage for African countries

using data from household surveys, ITN deliveries by manufacturers and

ITNs distributed by NMCPs. Tanya Shewchuk and others from ACT Watch

prepared analysis and text on the availability of parasitological diagnosis and

antimalarial medicines in Chapter 5 on diagnosis and treatment. Staff from the

Global Fund assisted in the conduct of rapid impact assessments presented

in Chapter 6 on the impact of malaria control. Madeleine Thomson, Pietro

Ceccato, and Michael Bell at International Research Institute for Climate and

Society, The Earth Institute at Columbia University, New York, and Hannah

Gould and Steve Yoon at Centers for Disease Control and Prevention, Atlanta

prepared analysis of the relationship between climate and disease trendsin selected African countries. Li Liu, Hope Johnson, Jamie Perin and Bob

Black of Johns Hopkins University, Baltimore, prepared estimates of malaria

mortality for children living in sub-Saharan Africa. Colin Mathers (WHO)

assisted in aligning the estimates of malaria deaths with the Global Burden

of Disease Project.

Erin Eckert (Macro International Inc.), Rick Steketee (Malaria Control and

Evaluation Partnership in Africa), Mathew Blakley, Ryuichi Komatsu, Eline

Korenromp, Estifanos Shargie (Global Fund) reviewed drafts of chapters and

made suggestions for their improvement.

The World Malaria Report 2010 was produced by Maru Aregawi,

Richard Cibulskis, Yosuke Kita, Mac Otten, and Ryan Williams on behalf

of the WHO Global Malaria Programme. Other colleagues in the Global

Malaria Programme also contributed to the production of chapters: AmyBarrette, David Bell, Andrea Bosman, Jo Lines, Kamini Mendis, Jose Nkuni,

Sivakumaran Murugasampillay, Robert Newman, Peter Olumese, Aafje

Rietveld, Pascal Ringwald, Silvia Schwarte. We also thank Lindsay Martinez

for editing, and Simone Colairo-Valerio, Anne Damnon and Joan Griffith for

administrative support.

Funding for the production of this Report was gratefully received from

Amelior Foundation, the Global Fund, the Government of Japan, the Roll

Back Malaria Partnership, and the United States Agency for International

Development.

7/21/2019 malaria 2010 who

10/93W O RLD M ALARIA REPO RT 2010 ix

AbbreviationsABER Annual blood examination rate

ACT Artemisinin-based combination therapy

AIDS Acquired immunodeficiency syndromeAMFm Affordable Medicine Facility malaria

AMP Alliance for Malaria Prevention

API Annual parasite incidence

CDC US Centers for Disease Control and Prevention

CHERG WHO Child Health Epidemiology Reference Group

DDT Dichloro-diphenyl-trichloroethane

DHS Demographic and health survey

G6PD Glucose-6-phosphate dehydrogenase

GBD Global burden of disease

Global Fund The Global Fund to fight AIDS, Tuberculosis and MalariaGMP Global Malaria Programme, WHO

HIV Human immunodeficiency virus

HMIS Health management information system

IAEG Inter-Agency and Exper t Group on MDG Indicators

IEC Information, education and communication

IHME Institute for Health Metrics and Evaluation

IPTi Intermittent preventive treatment in infants

IPTp Intermittent preventive treatment in pregnancy

IRS Indoor residual spraying

ITN Insecticide-treated mosquito netsLLIN Long-lasting insecticide-treated mosquito nets

MDG Millennium Development Goal

MERG RBM Monitoring and evaluation reference group

MICS Multiple indicator cluster survey

MIS Malaria indicator survey

NGO Nongovernmental organization

NMCP National malaria control programme

ODA Official development aid

OECD Organisation for Economic Co-operationand Development

PATH Program for Appropriate Technology in Health

PMI The US President s Malaria Initiative

RBM Roll Back Malaria Partnership

RDT Rapid diagnostic test

SP Sulfadoxine-pyrimethamine

SPR Slide positivity rate

SUFI Scaling Up for Impact

U5MR Under five mortality rate

UNICEF United Nations Childrens Fund

USAID United States Agency for Internat ional Development

VAMCM Verbal autopsy multi-cause model

WER Weekly Epidemiological Record

WHA World Health Assembly

WHOPES WHO Pesticide Evaluation Scheme

Abbreviations of antimalarial medicines

AQ Amodiaquine

AL Artemether-lumefantrine

AM Artemether

ART Artemisinin

AS Artesunate

CL Clindamycin

CQ Chloroquine

D Doxycycline

DHA Dihydroartemisinin

MQ Mefloquine

NQ Naphroquine

PG Proguanil

PPQ Piperaquine

PQ Primaquine

PYR Pyronaridine

QN Quinine

SP Sulfadoxine-pyrimethamine

T Tetracycline

(d) Days on treatment course

Abbreviations of WH O Regions / Of fices

AFRO: WHO Regional Office for Africa

AMRO: WHO Regional Office for the Americas

EMRO: WHO Regional Office for the Eastern

Mediterranean

EURO: WHO Regional Office for Europe

SEARO: WHO Regional Office for South-East Asia

WPRO: WHO Regional Office for the Western Pacific

7/21/2019 malaria 2010 who

11/93

7/21/2019 malaria 2010 who

12/93W O RLD M ALARIA REPO RT 2010 xi

Summary

The World Malaria Report 2010summarizes information received

from 106 malaria-endemic countries/areas and other partners andit updates the analyses presented in the 2009 Report. It highlightscontinued progress made towards meeting international targets formalaria control to be achieved by 2010 and 2015. The report outlines theevolving situation of financing for malaria control, how these growingresources have resulted in increased coverage of WHO-recommendedmalaria control interventions, and the association between this rapidscale-up and substantial reductions in malaria burden.

International funding for malaria control has risen steeply in thepast decade. Disbursements reached their highest ever levels in 2009at US$ 1.5 billion, but new commitments for malaria control appearto have stagnated in 2010, at US$ 1.8 billion. Countries with smaller

populations at risk continue to receive more funding per person at riskthan more populous countries. The amounts committed to malaria,while substantial, still fall short of the resources required for malariacontrol, estimated at more than US$ 6 billion for the year 2010.

The increased financing has resulted in tremendous progress inincreasing access to insecticide-treated mosquito nets (ITNs) in thepast 3 years. By the end of 2010, approximately 289 million ITNs willhave been delivered to sub-Saharan Africa, enough to cover 76% ofthe 765 million persons at risk of malaria. It is estimated that 42% ofhouseholds in Africa owned at least one ITN in mid-2010, and that35% of children slept under a ITN. The percentage of children using

ITNs is still below the WHA target of 80% partly because up to the endof 2009, ITN ownership remained low in some of the largest Africancountries. Low rates of use reported in some surveys are primarilydue to a lack of sufficient nets to cover all household members;household survey results suggest that most (80%) of the availableITNs are used.

While the rapid scale-up of ITN distribution in Africa represents anenormous public health achievement, it also represents a formidablechallenge for the future in ensuring that the high levels of coverage aremaintained. The lifespan of a long-lasting ITN is currently estimatedto be 3 years. Nets delivered in 2006 and 2007 are therefore alreadydue for replacement, and those delivered between 2008 and 2010

soon will be. Failure to replace these nets could lead to a resurgenceof malaria cases and deaths.

IRS programmes have also expanded considerably in recent years,with the number of people protected in sub-Saharan Africa increas-ing from 13 million in 2005 to 75 million in 2009, corresponding toprotection for approximately 10% of the population at risk in 2009.

Current methods of malaria vector control are highly dependenton a single class of insecticides, the pyrethroids, which are the mostcommonly used compounds for IRS and the only insecticide classused for ITNs. The widespread use of a single class of insecticidesincreases the risk that mosquitoes will develop resistance, which

could rapidly lead to a major public health problem. The risk is ofparticular concern in Africa, where insecticidal vector control is beingdeployed with unprecedented levels of coverage and where theburden of malaria is greatest.

WHO now recommends that all cases of suspected malaria be

confirmed with a diagnostic test prior to treatment. As the incidenceof malaria decreases through much of sub-Saharan Africa, the needto differentiate malaria from non-malarial fevers becomes morepressing. The proportion of reported cases in Africa confirmed witha diagnostic test has risen substantially from less than 5% at thebeginning of the decade to approximately 35% in 2009, but lowrates persist in the majority of African countries and in a minority ofcountries in other regions. A small number of countries have shownthat it is possible to scale up rapidly the availability of malaria diag-nostic testing on a national scale, provided that attention is given toadequate preparation, training, monitoring, supervision and qualitycontrol. Such experiences have been linked with large savings in

the use of artemisinin-based combination therapies (ACTs) and withimproved malaria surveillance.

Information from manufacturers indicates that the number ofACTs procured has increased in every year since 2005. By the end of2009, 11 African countries were providing sufficient courses of ACTsto cover more than 100% of malaria cases seen in the public sector;a further 8 African countries delivered sufficient courses to treat50%100% of cases. These figures represent a substantial increasesince 2005, when only 5 countries were providing sufficient coursesof ACT to cover more than 50% of patients treated in the publicsector. However, information on access to treatment is generallyincomplete, particularly for the significant proportion of patients

treated in the private sector.

The use of oral artemisinin-based monotherapies threatensthe therapeutic life of ACTs by fostering the spread of resistance toartemisinins. By November 2010, 25 countries were still allowingthe marketing of these products and 39 pharmaceutical companieswere manufacturing them. Most of the countries that still allow themarketing of monotherapies are located in the African Region andmost of the manufacturers are in India.

The spread of resistance to antimalarial medicines over the pastfew decades has led to an intensification of efficacy monitoring toallow early detection of resistance. Despite the observed changes

in parasite sensitivity to artemisinins, the clinical and parasitologicalefficacy of ACTs has not yet been compromised, even in the GreaterMekong sub-region. Nonetheless, both components of the drugcombination are currently at risk and using an ACT with an ineffec-tive partner medicine can increase the risk of development or spreadof artemisinin resistance.

A total of 11 countries and one area in the WHO African Regionshowed a reduction of more than 50% in either confirmed malariacases or malaria admissions and deaths in recent years. A decrease ofmore than 50% in the number of confirmed cases of malaria between2000 and 2009 was found in 3 of the 56 malaria-endemic countries

outside Africa, while downward trends of 25%50% were seen in 8other countries. Morocco and Turkmenistan were certified by theDirector-General of WHO in 2010 as having eliminated malaria.

1

7/21/2019 malaria 2010 who

13/93xii W O RLD M ALARIA REPO RT 2010

In 2009, the European Region reported no locally acquired casesof P. falciparum malaria for the first time.

It is estimated that the number of cases of malaria rose from 233million in 2000 to 244 million in 2005 but decreased to 225 millionin 2009. The number of deaths due to malaria is estimated to havedecreased from 985 000 in 2000 to 781 000 in 2009. Decreases inmalaria burden have been observed in all WHO Regions, with thelargest proportional decreases noted in the European Region,

followed by the Region of Americas. The largest absolute decreasesin deaths were observed in Africa.

While progress in reducing the malaria burden has been remark-able, there was evidence of an increase in malaria cases in 3 countriesin 2009 (Rwanda, Sao Tome and Principe, and Zambia). The reasonsfor the resurgences are not known with certainty. The increases inmalaria cases highlight the fragility of malaria control and the needto maintain control programmes even if numbers of cases have beenreduced substantially. The experiences in Rwanda and Zambia alsoindicate that monthly monitoring of disease surveillance data, bothnationally and subnationally, is essential. Since many countries in

sub-Saharan Africa had inadequate data to monitor disease trends,it is apparent that greater efforts need to be made to strengthenroutine surveillance systems. Major epidemiological events could beoccurring in additional countries without being detected and inves-tigated.

7/21/2019 malaria 2010 who

14/93

Key points

Background and contextMalaria-endemic countries and the global community arescaling up ef fective interventions to attain both coverage andimpact targets for 2010 and beyond.

1. On World Malaria Day 2008, the United Nations Secretary-Gen-eral called for efforts to ensure universal coverage with malariaprevention and treatment programmes by the end of 2010.

2. The goal established by the World Health Assembly in 2005and by the Roll Back Malaria (RBM) Partnership is to reduce thenumbers of malaria cases and deaths recorded in 2000 by 50% ormore by the end of 2010 and by 75% or more by 2015.

3. In September 2008, the RBM Partnership launched the GlobalMalaria Action Plan, which defines the steps required to acceler-ate achievement of the 2010 and 2015 targets for malaria controland elimination.

Policies and strategies for malaria control

To attain the 2010 and 2015 targets, countries must reach allpersons at risk for malaria with an insecticide-treated

mosquito net (ITN) or indoor residual spraying (IRS) andprovide laboratory-based diagnosis for all suspected cases ofmalaria and effective treatment of all confirmed cases.

Prevention

4. In 2009, 23 countries in the WHO African Region and 42 in otherWHO Regions had adopted the WHO recommendation toprovide ITNs for all persons at risk for malaria, not just womenand children; this represents an increase of 13 countries since2008. A total of 83 countries, of which 39 are in the African Region,distribute ITNs free of charge.

5. IRS with WHO-approved chemicals (including DDT) remains oneof the main interventions for reducing and interrupting malariatransmission by vector control in all epidemiological settings. In2009, 71 countries, including 27 in the African Region, reportedimplementation of IRS and 17 countries reported using DDT forIRS.

6. Intermittent preventive treatment (IPT) is recommended forpopulation groups in areas of high transmission who are particu-larly vulnerable to contracting malaria or suffering its conse-quences, particularly pregnant women and infants. A total of 35of 45 sub-Saharan African countries had adopted IPT for pregnant

women (IPTp) as national policy by the end of 2008. Papua NewGuinea, in the Western Pacific Region, also adopted this policyin 2009. No country has yet adopted a national policy of IPT forinfants (IPTi).

Diagnosis and treatment7. Prompt parasitological confirmation by microscopy or with a

rapid diagnostic test (RDT) is recommended for all patients withsuspected malaria, before treatment is started. In 2008, 33 of 43malaria-endemic countries in the African Region and 45 of 63countries in other Regions reported having a policy of parasito-logical testing of suspected malaria cases in persons of all ages,and 77 of 86 countries with endemic Plasmodium falciparumreported a policy of treatment with an artemisinin-based combi-nation therapy (ACT) forP. falciparum malaria.

8. Confirmed cases of uncomplicated P. falciparum malaria should

be treated with an ACT. P. vivax malaria should be treated withchloroquine where it is effective, or an appropriate ACT in areaswhere P. vivax is resistant to chloroquine. Treatment of P. vivaxshould be combined with a 14-day course of primaquine toprevent relapse.

9. WHO recommends that oral artemisinin-based monotherapiesbe withdrawn from the market and replaced with ACTs. ByNovember 2010, 25 countries were still allowing the marketing ofthese products (down from 37 in 2009) and 39 pharmaceuticalcompanies were manufacturing them. Most of the countries thatstill allow the marketing of monotherapies are in the AfricanRegion, while most of the manufacturers of these medicines are

in India.

Financing malaria control

The funds committed to malaria control from internationalsources have increased consistently between 2004 and 2009;funds remained at US$ 1.8 billion in 2010, substantiallylower than the resources required to achieve global targets,estimated at more than US$ 6 billion for the year 2010.

10. International funds disbursed for malaria control are estimatedto have increased from US$ 200 million in 2004 to US$ 1.5 billionmillion in 2009. Spending by national governments on malariacontrol appears to have risen in all WHO Regions between 2004and 2009; thus large increases in donor financing do not appearto have resulted in an overall reduction in the level of domesticfinancing, although countries which had reduced their spendingreceived more external financing than those which had increasedtheir domestic spending on malaria.

11. Of 106 malaria-endemic countries and areas, 77 received externalassistance for malaria control between 2000 and 2008. The

highest per capita expenditure continued to be seen in countrieswith smaller populations at risk. External financing appears to beconcentrated on programme activities, particularly the procure-ment of ITNs, antimalarial medicines and IRS. A larger proportion

W O RLD M ALARIA REPO RT 2010 xiii

7/21/2019 malaria 2010 who

15/93xiv W O RLD M ALARIA REPO RT 2010

of national government financing is directed towards humanresources although significant amounts are also spent on anti-malarial medicines and IRS.

12. Countries in the pre-elimination and elimination phases appearto spend more per person at risk of malaria than countries inthe control phase. While the additional spending is partly dueto larger amounts of external financing, government financingexceeds that of external financing in countries in the pre-elimi-

nation and elimination stages.

Progress in preventing malaria

Coverage with ITNs is increasing rapidly in some countriesof Africa, household ITN ownership having risen to 42%

by mid-2010.

13. In less than 3 years between 2008 and 2010 a cumulative total of254 million ITNs were delivered to sub-Saharan Africa, enough

to cover 66% of the 765 million persons at risk. An additional35 million ITNs are scheduled for delivery before the end of2010, sufficient to cover a further 10% of the population at risk.However, considerably more work is required to ensure that ITNsreach all households where they are needed, and that persons atrisk of malaria sleep under an ITN every night.

14. A model-based estimate showed that 42% of African householdsowned at least one ITN, and 35% of children < 5 years of age sleptunder an ITN in 2010. Household ITN ownership was estimatedin this model to have reached 50% in 19 African countries in2010.

15. Household surveys undertaken between 2007 and 2009 foundthat 11 countries (Equatorial Guinea, Ethiopia, Gabon, Mali,Rwanda, Senegal, Sao Tome and Principe, Senegal, Sierra Leone,Togo, and Zambia) had reached a household ITN ownership rateof more than 50%. The median percentage of children < 5 yearsof age sleeping under an ITN in these countries was 45%. Lowrates of use reported in some surveys are primarily due to a lackof sufficient nets to cover all household members; a very highproportion (80%) of available ITNs is used.

16. Persons aged 519 years are least likely to use an ITN comparedto those in the younger and older age groups. Women areslightly more likely to sleep under an ITN than men (ratio women:men = 1.1); this is partly because pregnant women are more likelyto sleep under an ITN than other women. There is no differencein usage rates between female and male children < 5 years of age(ratio girls: boys = 0.99).

17. The number of people protected by IRS increased in sub-SaharanAfrica from 13 million in 2005 to 75 million in 2009, a quantitywhich corresponds to protection for 10% of the population at riskin 2009.

18. In other WHO Regions, the number of ITNs delivered by manu-facturers or distributed by NMCPs is smaller than in Africa(16.4 million 2009), but has been increasing at a similar rate.IRS implementation is relatively stable with 98 million peopleprotected in 2009 (69 million in India). With the exception ofIndia, the proportion of the population protected by IRS tends

to be smaller than in the African countries which use IRS, possiblybecause of the more focal nature of malaria outside Africa.

19. Current methods of malaria control are highly dependent on asingle class of insecticides, the pyrethroids, which are the mostcommonly used compounds for IRS and the only insecticide classused for ITNs. The widespread use of a single class of insecticideincreases the risk that mosquitoes will develop resistance, whichcould rapidly lead to a major public health problem, particularly

in Africa, where chemical vector control is being deployed withunprecedented levels of coverage and where the burden ofmalaria is greatest.

Progress on the preventionof malaria during pregnancy

Coverage with intermittent preventive treatment for pregnantwomen (IPTp) remains far from target levels, although a few

countries have made notable progress.20. The percentage of pregnant women who received the second

dose of IPTp ranged from 2.4% in Angola to 62% in Zambia,according to households surveys in 8 countries for which datawere available for 20072009. The weighted average, repre-senting a population of 270 million, remained low, at 12%, dueprimarily to low coverage rates in Nigeria.

21. Data reported by NMCPs in 22 high-burden countries in theAfrican Region indicate that the percentage of women attendingantenatal clinics who received the second dose of IPTp was 55%(inter-quartile range 47%61%).

Progress in the diagnosisand treatment of malaria

The number of RDTs and ACTs procured is increasing,and the percentage of reported suspected casesreceiving a parasitological test has increased from67% globally in 2005 to 73% in 2009. Many cases still

are treated without a parasitological diagnosis.

22. The percentage of reported suspected malaria cases receiving aparasitological test has increased between 2005 and 2009, partic-ularly in the African Region (from 26% to 35%), Eastern Mediterra-nean Region (47% to 68%) and South-East Asia Region excludingIndia (from 58% to 95%). Low rates persist in the majority ofAfrican countries: in 21 out of 42 countries which reported ontesting, the percentage of cases tested was less than 20%. Datafrom a limited number of countries suggest that both microscopyand RDTs are less widely available in the private sector than thepublic sector.

23. A small number of countries, including the Lao Peoples Demo-cratic Republic and Senegal, have shown that it is possible to

scale up rapidly the availability of malaria diagnostic testingnationwide, provided that attention is given to adequate prepa-ration, training, monitoring, supervision and quality control.

7/21/2019 malaria 2010 who

16/93W O RLD M ALARIA REPO RT 2010 xv

24. The number of ACT treatment courses procured increased greatlyfrom 11.2 million in 2005 to 76 million in 2006, and reached 158million in 2009. By the end of 2009, 11 African countries wereproviding sufficient courses of ACTs to cover more than 100%of malaria cases seen in the public sector; a further 8 Africancountries delivered sufficient courses to treat 50%100% ofcases. These figures represent a substantial increase since 2005,when only 5 countries were providing sufficient courses of ACT

to cover more than 50% of patients treated in the public sector.However, the number of ACTs distributed by NMCPs in the AfricanRegion in 2009 exceeded the number of RDTs procured morethan five-fold, and the total number of tests carried out (micros-copy + RDTs) by a factor of 2.4, indicating that many patients arereceiving ACTs without confirmatory diagnosis.

25. By combining household survey data with health facility data itcan be estimated that, on average, 65% of treatment needs arefulfilled for patients attending public health facilities. Estimatesare more difficult to construct for patients who are treated in theprivate sector, but household surveys indicate febrile patientstreated in the private sector are 25% less likely to receive an anti-malarial than those visiting public sector facilities, while thosethat stay at home are 60% less likely.

26. The use of oral artemisinin-based monotherapies threatensthe therapeutic life of ACTs by fostering the spread of resist-ance to artemisinin. By November 2010, 25 countries were stillallowing the marketing of these products and 39 pharmaceuti-cal companies were manufacturing these products. Most of thecountries that still allow the marketing of monotherapies arelocated in the African Region and most of the manufacturers arein India.

27. Parasite resistance has rendered previous antimalarial medicinesineffective in most parts of the world, jeopardizing malariacontrol. The highly effective artemisinin derivatives and theirpartner drugs are vulnerable to the same risk. Resistance ofP. falciparum to artemisinins was confirmed at the Cambodia-Thailand border in 2009 but despite the observed changes inparasite sensitivity to artemisinins, the clinical and parasitologi-cal efficacy of ACTs has not yet been compromised. Since 2008,containment activities to limit the spread of artemisinin-resistantparasites have been ongoing.

Impact of malaria control

A growing number of countries have recorded decreases inthe number of confirmed cases of malaria and/or reported

admissions and deaths since 2000. Global control efforts haveresulted in a reduction in the estimated number of deaths fromnearly 1 million in 2000 to 781 000 in 2009.

28. A total of 11 countries and one area in the African Region showeda reduction of more than 50% in either confirmed malaria cases ormalaria admissions and deaths in recent years (Algeria, Botswana,Cape Verde, Eritrea, Madagascar, Namibia, Rwanda, Sao Tome

and Principe, South Africa, Swaziland, Zambia, and Zanzibar,United Republic of Tanzania). In all countries, the decreases areassociated with intense malaria control interventions.

29. In 2009 there was evidence of an increase in malaria cases in threecountries that had previously reported reductions (Rwanda, SaoTome and Principe, and Zambia). The reasons for these resur-gences are not known with certainty, but they highlight thefragility of progress in malaria control and the need to rigor-ously maintain control programmes even when cases have beenreduced substantially.

30. In other WHO Regions, the number of reported cases of confirmed

malaria decreased by more than 50% in 3 of the 56 malaria-en-demic countries between 2000 and 2009 and downward trendsof 25%50% were seen in 8 other countries. In 2009, the EuropeanRegion reported no locally acquired cases of P. falciparummalariafor the first time. The number of cases fell least in countries withthe highest incidence rates, indicating that greater attentionshould be given to countries which harbour most of the malariaburden outside Africa.

31. There were 8 countries in the pre-elimination stage of malariacontrol in 2009 and 10 countries are implementing eliminationprogrammes nationwide (6 having entered the elimination phase

in 2008). A further 9 countries (Armenia, Bahamas, Egypt, Jamaica,Morocco, Oman, Russian Federation, Syrian Arab Republic, andTurkmenistan) are in the phase of preventing re-introductionof malaria. Morocco and Turkmenistan were certified as free ofmalaria by the WHO Director-General in 2010.

32. It is estimated that the number of cases of malaria rose from 233million in 2000 to 244 million in 2005 but decreased to 225 millionin 2009. The number of deaths due to malaria is estimated to havedecreased from 985 000 in 2000 to 781 000 in 2009. Decreases inmalaria burden have been observed in all WHO Regions, with thelargest proportional decreases noted in the European Region,followed by the Region of the Americas. The largest absolutedecreases in deaths were observed in Africa.

1

7/21/2019 malaria 2010 who

17/93xvi W O RLD M ALARIA REPO RT 2010

Avant-propos

Dr Margaret Chan,Directeur gnral de lOrganisation mondiale de la Sant

Lanalyse de rentabilit que lon peut faire la lumiredes conclusions duRapport 2010 sur le paludisme dans lemonde apporte des arguments supplmentaires en faveurdun investissement dans la lutte antipaludique. Lacclrationdu mouvement en vue dassurer une couverture universelleau moyen des dispositifs actuels, que le Secrtaire gnraldes Nations Unies a appele de ses vux en 2008, continuede porter ses fruits. Entre 2008 et 2010, prs de 289 millions

de moustiquaires imprgnes dinsecticide (MII) auront tfournies lAfrique subsaharienne, un nombre suffisant pourprotger 578 millions de personnes. En Afrique, 75 millionsde personnes, soit 10 % de la population expose au risque,ont galement t protges grce des pulvrisationsintradomiciliaires dinsecticides effet rmanent (PID). Ce sontl des rsultats concrets.

Cet effort de prvention a des consquences mesurablesen termes de sant publique. Le nombre de cas et de dcsimputables chaque anne au paludisme poursuit son dclin,notamment en Afrique. Les pays qui sont parvenus rduire de

moiti leur charge de morbidit palustre au cours de la derniredcennie sont toujours plus nombreux. Pour la premire fois,aucun cas de paludisme falciparum na t signal en 2009dans la Rgion OMS de l Europe. Nous voyons le nombredes pays dendmie palustre se rduire pays par pays. Rienque cette anne, jai eu lhonneur de certifier le Maroc et leTurkmnistan exempts de paludisme et jai pu inscrire ces paysauRegistre des zones o llimination du paludisme a t ralise.

Des changements majeurs sont en train de faire voluerrapidement notre faon de nous attaquer au paludisme. Cetteanne, nous avons enfin dclar que tout cas suspect de

paludisme avait droit un diagnostic de confirmation. Il taitgrand temps de le faire. On a trop longtemps et en trop de lieuxassimil chaque cas de fivre un cas de paludisme. Ce tempsest rvolu. Nos efforts de prvention ont rellement modifi latransmission du paludisme et mme en Afrique, la plupart descas de fivre ne sont plus dus au paludisme. Voil encore unsigne indiscutable de progrs qui traduit le perfectionnementconstant de nos stratgies de lutte. Nous disposons de testsde diagnostic rapide, peu coteux, de qualit garantie et quipeuvent tre effectus tous les niveaux, et mme celui de lacommunaut.

En 2009, plus dun tiers des cas suspects de paludismenotifis en Afrique ont t confirms par un test de diagnostic,ce qui reprsente une augmentation spectaculaire par rapportaux moins de 5 % que lon enregistrait au dbut de la dcennie.

Dans un petit nombre de pays africains, on est parvenu passerrapidement lchelon national en matire de diagnostic.Cela a permis non seulement dconomiser chaque annedes milliers de traitements inutiles laide dassociationsthrapeutiques base dartmisinine (ACT), mais encorede donner les moyens de surveiller le paludisme en tempsopportun et de manire fiable. Cest l une importante avance.Ce nest quen dcouvrant o se cache lennemi, en localisant les

zones o il svit encore, que nous pouvons esprer le vaincre.

Sil est vrai quil y a lieu de se rjouir, les donnes qui figurentdans ce rapport mettent en vidence la fragilit de nos progrs.Une rsurgence du paludisme a t observe dans certaineszones dau moins trois pays africains. Les raisons de cette forteaugmentation ne sont pas connues avec exactitude, maiselles tiennent probablement la conjugaison de variationsnaturelles et de dfaillances dans les mesures de lutte. Ceschecs programmatiques nous rappellent ce qui pourraitarriver en devenant moins vigilants ou en ne donnant passuite nos engagements collectifs. A bien des gards, plus que

dtre dj parvenus assurer un taux lev de couverture pardes mesures de prvention et de lutte antipalustre, cest denassurer la durabilit qui risque de poser problme.

Nous ne pouvons pas laisser cette dynamique sessouffler.Nos rcents acquis sont importants mais fragiles et nousdevons les prenniser. Il faut que la communaut internationaleassure, au niveau mondial, un financement qui soit lafois prvisible et suffisant pour atteindre, dans le cadre desefforts dploys en vue de la ralisation en 2015 des objectifssanitaires du millnaire pour le dveloppement, les ciblesambitieuses qui ont t fixes en matire de lutte contre le

paludisme.

Il faut que la volont de maintenir les acquis de la lutteantipaludique mane non seulement des chefs de file delaction sanitaire mondiale ou des responsables politiques,mais aussi des communauts concernes. Pour autant que cescommunauts puissent se rendre compte de la charge relleque le paludisme fait peser sur elles et des rsultats obtenusgrce aux efforts dploys pour le prvenir et le juguler, lavolont dliminer et de finir par radiquer cette maladie nefaiblira jamais.

7/21/2019 malaria 2010 who

18/93W O RLD M ALARIA REPO RT 2010 xvii

Rsum

Le Rapport 2010 sur le paludisme dans le monde rcapituleles informations communiques par les 106 pays dendmiepalustre, ou manant dautres sources, et il met jour les analysesqui figurent dans le rapport 2009. Il met en lumire les progrsininterrompus accomplis vers la ralisation, en 2010 et 2015, desobjectifs internationaux en matire de lutte antipaludique. Lerapport voque galement les changements intervenus dans lasituation financire de la lutte antipaludique ; il montre commentles ressources croissantes dont elle dispose ont permis de diffuserplus largement les interventions recommandes par lOMSet indique en quoi le recul notable de la charge de morbiditpalustre est li ce passage rapide lchelle suprieure.

Les fonds dorigine internationale consacrs la lutteantipaludique ont fortement augment au cours de la derniredcennie. Cest en 2009 que les dpenses ont atteint le montantle plus lev jamais observ avec un total de 1,5 milliard US$, maisles nouveaux engagements en faveur de la lutte antipaludiqueont visiblement stagn en 2010, avec un montant de 1,8 milliardUS$. Les pays dont la population expose au risque est peunombreuse continuent recevoir davantage de fonds parpersonne expose au risque que les pays plus fortement peupls.Les sommes consacres au paludisme, pour importantes quellessoient, restent insuffisantes au regard des ressources ncessaires

pour combattre la maladie, lesquelles sont values plus de 6milliards US$ pour lanne 2010.

Ce financement accru a permis des progrs considrablesdans laccessibilit des moustiquaires imprgnes dinsecticides(MII) au cours des trois dernires annes. Fin 2010, environ289 millions de MII ont t fournies lAfrique subsaharienne,un nombre suffisant pour couvrir 76 % des 765 millions depersonnes exposes au risque de paludisme. On estime quaumilieu de lanne 2010, 42 % des mnages africains taient enpossession dune MII et que 35 % des enfants dormaient sous unetelle moustiquaire. Le pourcentage denfants utilisant une MII

est encore infrieur au chiffre de 80 % prconis par lAssemblemondiale de la Sant, en partie du fait que, jusqu fin 2009, il yavait encore peu de possesseurs de MII dans certains des plusgrands pays dAfrique. Les faibles taux dutilisation relevs parcertaines enqutes sexpliquent principalement par le nombreinsuffisant de moustiquaires pour quiper tous les membresdun mnage; les rsultats des enqutes indiquent que la plupart(80 %) des MII disponibles sont utilises.

Si la monte en che de la distribution de MII en Afriquereprsente un exploit considrable sur le plan de la santpublique, elle nen constitue pas moins un formidable dfi pour

lavenir, sagissant du maintien dun niveau lev de couverture.On estime que la dure de vie dune MII de longue dure(MILD) est actuellement de 3 ans. Les moustiquaires livresen 2006 et 2007 doivent donc dj tre remplaces, et celles

qui ont t livres en 2008 et 2009 devront ltre bientt. Lenon remplacement de ces moustiquaires pourrait entraner larapparition de cas et de dcs imputables au paludisme.

Les programmes de pulvrisations intradomiciliaires dinsec-ticides effet rmanent (PID) ont connu un dvelop pementtrs important en Afrique subsaharienne au cours des derniresannes, le nombre de personnes protges passant de 13millions en 2005 75 millions en 2009, soit un taux de couverturedenviron 10 % de la population expose au risque en 2009.

Les mthodes actuelles de lutte antivectorielle dpendenten trs grande partie dune seule classe dinsecticides, les

pyrthrinodes, qui sont les composs les plus courammentutiliss pour les PID et les seuls qui servent imprgner lesmoustiquaires. En gnralisant lusage dune seule et uniqueclasse dinsecticides, on accrot le risque de voir apparatre,chez les moustiques vecteurs, une rsistance qui pourraitdevenir rapidement un problme majeur de sant publique. Cerisque est particulirement proccupant en Afrique, o la lutteantivectorielle au moyen dinsecticides est actuellement meneavec des niveaux de couverture sans prcdent et o la chargede morbidit palustre est la plus leve.

LOMS recommande dsormais que tous les cas suspects

de paludisme soient confirms par un test de diagnosticpralablement tout traitement. Maintenant que lincidencedu paludisme recule dans une grande partie de lAfriquesubsaharienne, la ncessit de diffrencier une fivre palustredun tat fbrile ayant une autre origine se fait plus pressante.En Afrique, la proportion de cas notifis comme cas confirmspar un test de diagnostic a sensiblement augment, passantde moins de 5 % au dbut de la dcennie environ 35 % en2009, mais cette proportion reste faible dans la plupart des paysdAfrique et dans un petit nombre de pays des autres Rgions.Dans un petit nombre de pays, on a montr quil tait possible

daccrotre rapidement la disponibilit des tests de diagnosticrapide lchelon national, en veillant assurer une prparation,une formation, un suivi, un encadrement et un contrle de qualitadquats. En lien avec ces expriences, il y a eu dimportantesconomies dans lutilisation des combinaisons thrapeutiques base dartmisinine (CTA) et une meilleure surveillance dupaludisme.

Daprs les renseignements communiqus par lesproducteurs, le nombre de CTA dlivres augmente chaqueanne depuis 2005. Fin 2009, 11 pays africains fournissaientsuffisamment de cures pour traiter plus de 100 % des cas de

paludisme vus dans le secteur public et 8 autres en ont dlivrsuffisamment pour traiter de 50 100 % des cas. Ces chiffrestraduisent une augmentation notable depuis 2005, anne oseulement 5 pays fournissaient suffisamment de cures pour

7/21/2019 malaria 2010 who

19/93xviii W O RLD M ALARIA REPO RT 2010

traiter plus de 50 % des malades pris en charge par le secteurpublic. Cela tant, les informations relatives laccessibilit dutraitement sont gnralement incompltes, notamment en cequi concerne la proportion importante de malades qui sonttraits dans le secteur priv.

Le recours aux monothrapies base dartmisinine parvoie orale constitue une menace pour la dure de validit

thrapeutique des CTA, dans la mesure o il favorise lapropagation dune rsistance aux artmisinines. En novembre2010, la commercialisation de ces produits tait encore autorisedans 25 pays et 39 firmes pharmaceutiques en fabriquaient. Laplupart des pays o la commercialisation des monothrapiesest encore autorise appartiennent la Rgion de lAfrique etpresque tous les producteurs se trouvent en Inde.

La rsistance aux antipaludens sest tendue au coursdes dernires dcennies et cela a conduit surveiller plusintensment lefficacit de ces produits afin de dceler dans lesplus brefs dlais lapparition dune telle rsistance. Malgr les

changements que lon observe dans la sensibilit des plasmodiesaux artmisinines, lefficacit clinique et parasitologique desCTA nest pas encore compromise, mme dans la sous-rgiondu Grand Mkong. Les deux constituants de cette associationmdicamenteuse nen sont pas moins menacs et utiliser uneCTA comportant un mdicament associ inefficace peut accrotrele risque de faire apparatre ou de propager la rsistance auxartmisinines.

Il y a 11 pays au total et un territoire dans la Rgion OMS delAfrique o le nombre des cas confirms de paludisme ou deshospitalisations et des dcs pour cause de paludisme a recul

de plus de 50 % au cours de ces dernires annes. Entre 2000 et2009, on a enregistr un recul de plus de 50 % des cas confirmsde paludisme dans 3 des 56 pays dendmie palustre situs horsdAfrique, une tendance descendante de lordre de 25 50 %tant observe dans 8 autres pays. En 2010, le Directeur gnralde lOMS a certifi que le Maroc et le Turkmnistan avaientlimin le paludisme. La mme anne et pour la premire fois,aucun cas de paludisme falciparum na t notifi dans laRgion OMS de l Europe.

On estime que le nombre de cas de paludisme est pass de233 millions en 2000 244 millions en 2005, mais quil a recul

225 millions en 2009. Selon les estimations, le nombre dedcs imputables au paludisme a recul de 985 000, en 2000, 781 000 en 2009. Une baisse de la charge de morbiditpalustre a t observe dans toutes les Rgions de lOMS.Proportionnellement, la baisse a t la plus marque dans laRgion de lEurope, suivie par la Rgion des Amriques. Envaleur absolue, cest en Afrique que le nombre de dcs a le plusrecul.

Si la rduction de la charge de morbidit palustre a remarqua-blement progress, on a les preuves dune augmentation des casdans 3 pays en 2009 (Rwanda, Sao Tom-et-Principe, Zambie).

Les raisons de cette rsurgence ne sont pas connues aveccertitude. Cette augmentation des cas de paludisme souligne lafragilit des acquis de la lutte antipaludique et la ncessit demaintenir les programmes de lutte mme si le nombre de cas a

sensiblement recul. Ce qui sest pass au Rwanda et en Zambiemontre galement quun contrle mensuel des donnes fourniespar la surveillance de la morbidit, tant au niveau national quauniveau infranational, est essentiel. Beaucoup de pays de lAfriquesubsaharienne nayant pas suffisamment de donnes pour suivreles tendances de la morbidit, il est clair que de grands effortssont encore faire pour renforcer les systmes de surveillancesystmatique. Des vnements pidmiologiques majeurs

pourraient se produire dans dautres pays sans tre dcels nisoumis investigation.

1

7/21/2019 malaria 2010 who

20/93W O RLD M ALARIA REPO RT 2010 xix

Points essentiels

Historique et contexteLes pays dendmie palustre et la communautinternationale interviennent efficacement et grandechelle pour atteindre, dici 2010 et au-del, les cibles

fixes en matire de couverture et dimpact.

1. Lors de lappel quil a lanc en 2008 loccasion de la Journemondiale du paludisme, le Secrtaire gnral des NationsUnies a souhait que des efforts soient dploys afin dassurerdici 2010 une couverture universelle par les programmes deprvention et de traitement de cette maladie.

2. En 2005, lAssemble mondiale de la Sant et le Partena-riat "Faire reculer le paludisme" (RBM) se sont fix pour butde rduire le nombre de cas et de dcs imputables aupaludisme dau moins 50 % dici fin 2010 et dau moins 75 %dici 2015 par rapport aux chiffres de 2000.

3. En septembre 2008, le Partenariat RBM a lanc un Planmondial daction contre le paludisme qui dfinit les mesurespermettant datteindre plus rapidement les cibles fixespour 2010 et 2015 en ce qui concerne lendiguement et lli-mination du paludisme.

Politiques et stratgiesde lutte antipaludique

Pour atteindre les cibles fixes pour 2010 et 2015, les paysdoivent faire en sorte que toutes les personnes exposes

au risque de paludisme aient accs aux moustiquairesimprgnes dinsecticide (MII) et aux pulvrisationsintradomicil iaires dinsecticides ef fet rmanent (PID), quetous les cas suspects de paludisme fassent lobjet dundiagnostic en laboratoire, et que tous les cas confirms

soient traits efficacement.

Prvention

4. En 2009, 23 pays appartenant la Rgion de lAfrique et 42pays situs dans dautres Rgions de lOMS avaient adoptles recommandations de l Organisation prconisant la four-niture de MII toutes les personnes exposes au risque depaludisme et pas uniquement aux femmes et aux enfants;cela reprsente 13 pays de plus quen 2008. Il y a au total 83pays dont 39 dans la Rgion de lAfrique , qui distribuent

gratuitement des MII toutes les personnes exposes aurisque de paludisme.

5. Les pulvrisations intradomiciliaires (PID) l'aide dinsecti-cides effet rmanent agrs par lOMS (y compris le DDT)

constituent encore la principale mesure de lutte antivecto-rielle destine rduire ou interrompre la transmission dupaludisme dans tous les contextes pidmiologiques. En2009, 71 pays dont 27 situs dans la Rgion de lAfrique, onindiqu procder des pulvrisations intradomicilaires, 17de ces pays ayant recours au DDT pour ces oprations.

6. Un traitement prventif intermittent (TPI) est recommandpour les groupes de population vivant dans des zones forte transmission et qui sont particulirement exposs contracter le paludisme ou souffrir de ses consquen-ces, notamment les femmes enceintes et les nourrissons.

Sur 45 pays de lAfrique subsaharienne, il y en a 35 qui, fin2008, avaient adopt le TPI comme politique nationale. Dansla Rgion du Pacifique occidental, la Papouasie-NouvelleGuine a galement adopt cette politique en 2009. Aucunpays na pour linstant fait du TPI un lment de sa politiquenationale dans le cas des nourrissons.

Diagnostic et traitement

7. Une prompte confirmation parasitologique par examenmicroscopique ou au moyen dun test de diagnostic rapide

(TDR) est recommande avant tout traitement pour lensem-ble des cas suspects de paludisme. En 2008, 33 des 43 paysdendmie palustre situs dans la Rgion de lAfrique et 45des 63 qui font partie dautres Rgions ont indiqu avoirpour politique de pratiquer des examens parasitologiqueschez les cas suspects de paludisme appartenant toutes lesclasses dge et 77 des 86 pays o Plasmodium falciparumestendmique ont dclar que leur ligne de conduite tait detraiter le paludisme falciparum au moyen de combinaisonsthrapeutiques base dartmisinine (CTA).

8. Les cas confirms de paludisme simple falciparum doivent

tre traits au moyen dune association thrapeutique basedartmisinine. Le paludisme vivax doit tre trait par lachloroquine l o cet antipaluden reste efficace ou par uneCTA dans les zones o P. vivax est rsistant la chloroquine.Le traitement du paludisme vivax doit tre complt parladministration de primaquine pendant 14 jours afin dviterles rechutes.

9. LOMS recommande de retirer du march les monothrapies base dartmisinine et de les remplacer par des CTA. Ennovembre 2010, 25 pays autorisaient encore la commercia-lisation de ces produits (ils taient 37 en 2009) et 39 firmes

pharmaceutiques les fabriquaient. La plupart des pays o lacommercialisation des monothrapies est encore autoriseappartiennent la Rgion de lAfrique, tandis que la plupartdes fabricants de ces mdicaments se trouvent en Inde.

7/21/2019 malaria 2010 who

21/93xx W O RLD M ALARIA REPO RT 2010

Financement de la lutte antipaludique

Les fonds qui sont affects la lutte antipaludique provenantde sources de financement internationales ont rgulirement

augment entre 2004 et 2009, mais ils ont stagn en 2010avec un montant de 1,8 milliard US$ et restent sensiblementinfrieurs aux ressources ncessaires pour at teindre les cibles

fixes au niveau mondial, ressources que lon value plus de6 milliards US$ pour lanne 2010.

10. On estime que les fonds internationaux affects la lutteantipaludique sont passs de 200 millions US$ en 2004 1,5milliard US$ en 2009. Il apparat que les montants dpensspar les pouvoirs publics nationaux au titre de la lutte contrele paludisme ont augment dans toutes les Rgions de lOMSentre 2004 et 2009 ; il semble donc que la forte augmenta-tion des fonds allous par des donateurs nait pas eu poureffet de rduire globalement le financement par des fondsnationaux, encore que les pays qui avaient rduit leurs

dpenses aient reu davantage de fonds extrieurs que ceuxqui avaient consacr davantage de fonds dorigine nationale la lutte antipaludique.

11. Entre 2000 et 2008, sur les 106 pays ou territoires dendmiepalustre, 77 ont reu une aide extrieure au titre de la luttecontre le paludisme. Cest dans les pays dont la popula-tion expose au risque tait la plus faible que lon a encoreobserv les dpenses par habitant les plus leves. Onconstate que le financement extrieur est ax sur les activitsprogrammatiques, notamment la fourniture de MII et dan-tipaludens, ainsi que sur les PID. Les fonds allous par les

pouvoirs publics sont consacrs pour une plus grande partaux ressources humaines, mais des montants importantssont tout de mme affects aux antipaludens et aux pulv-risations intradomiciliaires.

12. On observe que les pays qui se trouvent en phase de pr-limination ou dlimination dpensent davantage parpersonne expose au risque que ceux qui sont en phase delutte. Laccroissement des dpenses sexplique en partie parlaugmentation du financement extrieur, mais dans les paysqui sont en phase de pr-limination ou dlimination, lemontant des fonds allous par les pouvoirs publics dpasse

celui du financement extrieur.

Progrs dans la prvention du paludisme

La couverture en moustiquaires imprgnes dinsecticidesaccrot rapidement dans certains pays dAfrique et 42 % desmnages en taient propritaires au milieu de lanne 2010.

13. Entre 2008 et 2010, cest--dire en moins de 3 ans, 254 millionsde MII ont t fournies au total lAfrique subsaharienne, une

quantit suffisante pour protger 66 % des 765 millions dha-bitants exposs au risque. Il est prvu den fournir 35 millionsde plus avant la fin de 2010, ce qui permettra dtendre laprotection encore 10 % de cette population. Il faudra

nanmoins encore beaucoup defforts pour en doter tous lesmnages qui en ont besoin et faire en sorte que tous ceuxqui sont exposs au risque puissent dormir chaque nuit sousune moustiquaire imprgne.

14. Selon une estimation par modlisation, 42 % des mnagesafricains taient en possession dau moins une MII et 35 %des enfants de moins de 5 ans dormaient en 2010 sous une

moustiquaire imprgne. On estime, selon ce modle, quedans 19 pays dAfrique, la proportion de mnages dten-teurs de moustiquaires a atteint 50 % en 2010.

15. Les enqutes effectues auprs des mnages entre 2007 et2009 rvlent que dans 11 pays (Ethiopie, Gabon, Guinequatoriale, Mali, Rwanda, Sao Tom-et-Principe, Sngal,Sierra Leone, Togo et Zambie) la proportion des mnagespossdant une MII avait atteint 50 %. Dans ces pays, lepourcentage mdian denfants de moins de 5 ans dormantsous une moustiquaire imprgne tait de 45 %. Les faiblestaux dutilisation relevs par certaines enqutes sexpliquent

principalement par le nombre insuffisant de moustiquairespour protger tous les membres du mnage; la proportionde moustiquaires disponibles effectivement utilises est trsleve (80%).

16. Cest dans la tranche dge de 5 19 ans que la probabi-lit dutiliser une MII est la plus faible comparativementaux groupes plus jeunes ou plus gs. Chez les femmes, laprobabilit de dormir sous une moustiquaire imprgne estlgrement plus leve (rapport femmes/hommes : 1,1); celatient en partie au fait que les femmes enceintes ont plus dechances de dormir sous une MII que les autres femmes. Il ny

a aucune diffrence dans le taux dutilisation entre les filles etles garons de moins de 5 ans (rapport filles/garons: 0,99).

17. Le nombre de personnes protges par des PID a augmenten Afrique subsaharienne, passant de 13 millions en 2005 75 millions en 2009, ce qui signifie quen 2009, 10 % de lapopulation expose au risque tait protge.

18. Dans les autres Rgions de lOMS, le nombre de MII livres parles fabricants ou distribues par les programmes nationauxde lutte antipaludique est plus faible quen Afrique (16,4millions en 2009), mais il augmente un rythme similaire. Lamise en uvre des PID se maintient dune faon gnrale

son niveau historique avec 98 millions de personnes quitaient protges par cette mesure en 2009 (69 millions enInde). A lexception de lInde, le pourcentage de la popula-tion qui bnficie de ce genre de protection tend tre plusfaible que dans les pays d Afrique o ces pulvrisations sonteffectues, peut-tre en raison du caractre plus focal de lamaladie en dehors de lAfrique.

19. Les mthodes actuelles de lutte antivectorielle dpendenten trs grande partie dune seule classe dinsecticides, lespyrthrinodes, qui sont les composs les plus courammentutiliss pour les PID et les seuls qui servent imprgner les

moustiquaires. En gnralisant lusage dune seule et uniqueclasse dinsecticides, on accrot le risque de voir apparatre,chez les moustiques vecteurs, une rsistance qui pourraitdevenir rapidement un problme majeur de sant publique,

7/21/2019 malaria 2010 who

22/93W O RLD M ALARIA REPO RT 2010 xxi

notamment en Afrique, o la lutte antivectorielle au moyendinsecticides est actuellement mene avec des niveaux decouverture sans prcdent et o la charge de morbiditpalustre est la plus leve.

Progrs dans la prvention dupaludisme au cours de la grossesse

En ce qui concerne la couver ture des femmes enceintes par letraitement prventif intermittent (TPI) on est encore loin davoir

atteint les cibles fixes, mme si quelques pays ont accomplides progrs notables.

20. Le pourcentage de femmes enceintes ayant reu la deuximedose du traitement prventif intermittent allait de 2,4 % enAngola 62 % en Zambie selon des enqutes auprs desmnages effectues dans 8 pays pour lesquels on possdaitdes donnes relatives la priode 20072009. La moyenne

pondre, qui correspond une population de 270 millionsde personnes, est reste faible, avec une valeur de 12 %, quisexplique principalement par le faible taux de couvertureenregistr au Nigria.

21. Selon les donnes communiques par les programmesnationaux de lutte antipaludique de 22 pays africains fortecharge de morbidit palustre, le pourcentage de femmesfrquentant les services de soins prnatals et ayant reu laseconde dose du TPI tait de 55 % (fourchette interquartile :47% 61 %).

Progrs dans le diagnosticet le traitement du paludisme

Le nombre de TDR et de CTA fournis est en augmentation etle pourcentage de cas suspects notifis qui sont soumis unexamen parasitologique est pass de 67 % en 2005 dans

lensemble du monde 73 % en 2009. De nombreux cassont encore traits sans diagnostic parasitologique pralable.

22. La proportion de cas suspects notifis soumis un examen

parasitologique a augment entre 2005 et 2009, notammentdans la Rgion de lAfrique (de 26 35 %), dans la Rgion dela Mditerrane orientale (de 47 68 %) et dans la Rgionde lAsie du Sud-Est, Inde non comprise (de 58 95 %). Cetteproportion reste faible dans la plupart des pays dAfrique:dans 21 des 42 pays qui ont communiqu des informa-tions sur cet examen, elle tait infrieure 20 %. Daprs lesdonnes fournies par un nombre limit de pays, il sembleraitque lexamen microscopique comme les TDR soient moinspratiqus dans le secteur priv que dans le secteur public.

23. Dans un petit nombre de pays, comme la Rpublique dmo-

cratique populaire lao et le Sngal, on a montr quil taitpossible daccrotre rapidement la disponibilit des tests dediagnostic rapide lchelon national, en veillant assurer

une prparation, une formation, un suivi, un encadrement etun contrle de qualit adquats.

24. Le nombre de cures de CTA fournies a beaucoup augment,passant de 11,2 millions en 2005 76 millions en 2006, pourculminer 158 millions en 2009. Fin 2009, 11 pays africainsfournissaient un nombre suffisant de ces cures pour traiterplus de 100 % des cas de paludisme vus dans le secteur public

et 8 autres pays de cette rgion en ont dlivr suffisammentpour traiter 50 100 % des cas. Ces chiffres traduisent uneaugmentation notable depuis 2005, o il ny avait que 5 paysqui fournissaient suffisamment de cures de CTA pour traiterplus de 50 % des malades soigns dans le secteur public.Toujours est-il que le nombre de CTA distribues en 2009par les programmes nationaux de lutte antipaludique dansla Rgion de lAfrique a reprsent plus de cinq fois celuides TDR fournis et 2,4 fois le nombre total de tests effectus(examen microscopique plus TDR), ce qui indique que denombreux malades ont t traits par des CTA sans diagnos-tic de confirmation.

25. En regroupant les donnes issues des enqutes auprsdes mnages et celles des tablissements de soins on peutestimer, quen moyenne, 65 % des besoins thrapeutiquessont satisfaits chez les malades qui frquentent les tablis-sements de soins du secteur public. Les estimations sontplus difficiles tablir sagissant des malades traits dansle secteur priv, mais les enqutes auprs des mnagesrvlent que pour les sujets fbriles soigns dans ce secteur,la probabilit dtre trait par un antipaluden est de 25 %infrieure celle quont les malades du secteur public derecevoir un tel produit ; quant aux malades qui restent chez

eux leur probabilit de recevoir un antipaluden est de 60 %infrieure.

26. Lutilisation de monothrapies base dartmisinine compro-met la dure de validit thrapeutique des CTA en facilitant lapropagation de la rsistance ces composs. En novembre2010, 25 pays autorisaient encore la commercialisationde ces monothrapies et 39 firmes pharmaceutiques lesfabriquaient. La plupart des pays qui autorisent encore lacommercialisation des monothrapies se trouvent dans laRgion de lAfrique et la majorit des fabricants, en Inde.

27. Dans la plupart des rgions du monde, la rsistance desplasmodies a rendu les anciens antipaludens inefficaces,mettant en pril la lutte antipaludique. Le mme genre derisque menace les antipaludens extrmement efficaces quesont les drivs de lartmisinine et les mdicaments qui leursont associs. La rsistance de P. falciparumaux artmisini-nes a t confirme en 2009 la frontire entre le Cambodgeet la Thalande, mais malgr lvolution de la sensibilit desplasmodies ces produits, lefficacit clinique et parasitolo-gique des CTA nest pas encore compromise. Depuis 2008,on sactive contenir la propagation des plasmodies rsis-tantes aux artmisinines.

7/21/2019 malaria 2010 who

23/93xxii W O RLD M ALARIA REPO RT 2010

Impact de la lutte antipaludique

Depuis 2000, les pays sont de plus en plus nombreux enregistrer une diminution du nombre de cas confirmsde paludisme ou du nombre dhospitalisations et de dcs

notifis. Les efforts de lut te dploys au niveau mondial ontentran une diminution du nombre estimatif de dcs, lechiffre passant de prs de 1 million en 2000, 781 000 en

2009.28. Dans 11 pays et 1 territoire de la Rgion africaine, on a enre-

gistr ces dernires annes un recul de plus de 50 % des casconfirms ou des hospitalisations et des dcs imputablesau paludisme (Afrique du Sud, Algrie, Botswana, Cap Vert,rythre, Madagascar, Namibie, Rwanda, Sao Tom-et-Prin-cipe, Swaziland, Zambie et Zanzibar en Rpublique Unie deTanzanie). Dans tous ces pays, ce recul est li dnergiquesinterventions de lutte antipaludique.

29. En 2009, on a constat une augmentation du nombre de casde paludisme dans 3 pays qui avaient auparavant fait tat dun

recul de ces cas (Rwanda, Sao Tom-et-Principe et Zambie).Les raisons de cette rsurgence ne sont pas connues aveccertitude, mais elle souligne la fragilit des progrs ralissdans la lutte contre le paludisme et la ncessit de maintenirfermement les programmes de lutte antipaludique, mmelorsque le nombre de cas a sensiblement diminu.

30. Dans les autres Rgions OMS, le nombre notifi de casconfirms a recul de plus de 50 % entre 2000 et 2009 dans3 des 56 pays dendmie palustre, et une tendance descen-dante de lordre de 25 50 % a t observe dans 8 autrespays. En 2009 et pour la premire fois, aucun cas de paludisme

falciparum na t signal dans la Rgion de lEurope. Lerecul du nombre de cas a t le moins marqu dans les payso les taux dincidence taient les plus levs, ce qui montrequil faut tre plus attentif aux pays qui reclent la majeurepartie de la charge de morbidit en dehors de lAfrique.

31. En 2009, 8 pays se trouvaient en phase de pr-liminationet 10 mettaient en uvre des programmes dlimination lchelon national (8 tant entrs en phase dlimination en2008). Neuf autres pays (Armnie, Bahamas, gypte, Fdra-tion de Russie, Jamaque, Maroc, Oman, Rpublique arabesyrienne et Turkmnistan) ont interrompu la transmission et

semploient empcher la rintroduction du paludisme. En2010, le Directeur gnral de lOMS a certifi que le Maroc etle Turkmnistan taient exempts de paludisme.

32. On estime que le nombre de cas de paludisme est pass de233 millions en 2000 244 millions en 2005, mais quil estretomb 225 millions en 2009. Selon les estimations, lenombre de dcs des suites du paludisme est tomb de 985000 en 2000 781 000 en 2009. Une diminution de la chargede morbidit a t observe dans toutes les Rgions OMS,la baisse tant proportionnellement la plus marque dans laRgion de lEurope, suivie par la Rgion des Amriques. En

valeur absolue, cest en Afrique que le recul le plus importantdu nombre de dcs a t observ.

1

7/21/2019 malaria 2010 who

24/93W O RLD M ALARIA REPO RT 2010 xxiii

Prefacio

Dra. Margaret Chan,Directora General de la Organizacin Mundial de la Salud

Los datos del Informe mundial sobre el paludismo 2010refuerzan los argumentos para invertir en la lucha antipaldica.La carrera para lograr una cobertura universal con lasherramientas disponibles a da de hoy, por la que hizo unllamamiento el Secretario General de las Naciones Unidas en2008, contina dando frutos. Entre 2008 y 2010 se habrndistribuido casi 289 millones de redes mosquiteras tratadas con

insecticida en el frica subsahariana, suficientes para proteger a578 millones de personas. En frica 75 millones de personas, un10% de la poblacin a riesgo, recibieron tambin proteccin en2009 mediante la fumigacin intradomiciliaria con insecticidas.Estos resultados constituyen unos autnticos logros.

Estas labores de prevencin estn teniendo una incidenciamesurable en la salud pblica. El nmero anual de casos depaludismo y muertes debidas a esta enfermedad continadisminuyendo, especialmente en frica. El nmero de pasesque durante la ltima dcada han conseguido reducir a lamitad la carga del paludismo que sufran sigue aumentando.

Por primera vez, en 2009 no se inform de ningn caso depaludismo debido a Plasmodium falciparumen la Regin deEuropa de la OMS. Uno por uno, se va reduciendo el nmero depases con paludismo endmico. Este mismo ao tuve el honorde certificar que Marruecos y Turkmenistn se encuentranlibres de paludismo, y pude aadir estos pases a la lista oficialde las zonas donde se ha logrado eliminar esta enfermedad.

Estn sucediendo rpidamente grandes cambios en la formaen que nos enfrentamos al paludismo. Este es el ao en quepor fin se declar que toda persona con un presunto caso depaludismo tiene derecho a una prueba de diagnstico que

lo confirme. Este cambio llega ms tarde de lo que debera.Durante demasiado tiempo se ha identificado como paludismola fiebre en demasiados sitios. Esto se acab. Nuestrasiniciativas de prevencin han provocado cambios reales en latransmisin del paludismo, y la mayora de los casos de fiebreya no se deben a ste, incluso en frica. Ello constituye otroindicativo claro de progreso, y una seal de cmo se depuranconstantemente las estrategias de control. Disponemos depruebas de diagnstico econmicas, rpidas y de calidadgarantizada que pueden utilizarse en todos los niveles, incluidoel de la comunidad.

En 2009, ms de una tercera parte de los presuntos casos depaludismo notificados en frica se confirmaron con una pruebade diagnstico, lo que representa un drstico incremento

con respecto al porcentaje inferior al 5% correspondienteal principio de la dcada. Una pequea cantidad de pasesafricanos han podido extender las pruebas de diagnsticodel paludismo a nivel nacional. Ello no solo ha significado quecada ao se evite el uso innecesario de centenares de milesde tratamientos con las terapias combinadas basadas en laartemisinina, sino que tambin ha permitido implanta