Weakened malaria control programs linked to majority of global resurgences

Funding cuts for malaria control are the single most common reason for the resurgence of the deadly disease, according to a new study that has linked overall weakened malaria control programs to the majority of global resurgences since 1930.

The study, published in the April 24 issue of the open-access Malaria Journal, analyzed the causes of 75 documented episodes of malaria resurgence throughout the world over the past 80 years, both in countries that were close to eliminating the disease and those with higher transmission rates that were attempting to control it.

Among those resurgences, 91 percent - or 68 out of the 75 - were caused at least in part by weakened malaria control programs, with 39 of the 68 tied to funding constraints, according to the research led by the Clinton Health Access Initiative, in conjunction with the UCSF Global Health Group and the Johns Hopkins Malaria Research Institute.

The study also categorized malaria resurgence according to whether it was related to increased intensity of malaria transmission due to population movement or weather changes, as well as technical obstacles such as drug and insecticide resistance. Full results can be found at www.malariajournal.com.

The results are significant in light of an estimated $9.7 billion gap between funds available and funds needed for malaria programs worldwide over the next three years, according to the international partnership Roll Back Malaria, a global partnership linked to the United Nations that is coordinating a plan among 500 member nations and organizations to eliminate the disease worldwide.

Included in that gap is the decision by the Global Fund to Fight AIDS, Tuberculosis and Malaria to postpone the majority of its malaria-based funding for new grants through 2013. As recently as 2009, the Global Fund was providing roughly half of the $2 billion in development assistance for malaria.

"We cannot afford to let history repeat itself," said Sir Richard Feachem, KBE, FREng, DSc (Med), PhD, the founding executive director of the Global Fund who now directs the UCSF Global Health Group. "It is imperative that we not lose the gains that these countries have achieved in malaria control."

Past failures to maintain such gains underscore the fragility of success in the field. Both Sri Lanka and India, for example, saw significant reductions of the illness in the 1960s, but both had dramatic resurgences when funding was withdrawn, the paper found.

In India, for example, the U.S. Agency for International Development funded an eradication program that led to a massive drop in annual malaria cases, from about 100 million in the early 20th century to about 100,000 in 1965. But when that commitment ended, malaria resurged to a peak of 6 million cases by 1976.

"Malaria control programs have been shown to be extremely successful in reducing the number of cases of malaria to very low levels, but history demonstrates that gains can be lost rapidly if financial and political support is not sustained," said lead author Justin Cohen, PhD, MPH of the Clinton Health Access Initiative. "Finding ways to ensure continued funding for malaria control today will be crucial to building on the gains of the past decade."

An estimated 216 million people contracted malaria in 2010 in 106 countries and 655,000 died from it, according to the World Health Organization (WHO), although the Institute for Health Metrics and Evaluation (IHME) estimates malaria deaths at 1.2 million that year. Nine in 10 of those deaths are in Africa, and 86 percent were in children under age five. WHO estimates that in countries where it is common, malaria can measurably lower the gross domestic product and consume nearly half of all public health expenditures.

Malaria eradication - defined as ending malaria worldwide vs. eliminating it within a specific geographic area - was a major public health effort in the first half of the 20th century and was intensively pursued after World War II. Since that effort was launched, 108 countries have eliminated malaria from within their borders, with another 36 countries moving rapidly toward that goal. Despite those efforts, almost half the world's population still lives in places where the disease is common.

Since 2000, investments in malaria control and efforts to apply low-cost solutions such as bed nets and indoor insecticide spraying on a broad scale had created unprecedented momentum in controlling malaria and brought several countries to the brink of elimination. The paper reflects the impact current funding declines could have in reversing those gains.