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Column: Problems on the Horizon

March 2, 2014 - 22:08 -- Bart G.J. Knols
As an avid observer of malaria transmission patterns, I am becoming worried about sustaining the advances that have developed over the past ten or so years. There is no doubt that the advent of insecticide treated bednets has provided a vehicle for various interested parties to exploit as a means of vector control, and this has happened in huge numbers. Tens of millions of LLINs have been delivered to various governments, NGOs and other interested parties, and this is still happening. But when it comes to monitoring the effects of this intervention, when it comes to careful evaluation of the programmes, there isn’t much to hear...

Most donors do not provide funds nor do they require any monitoring and evaluation. I am quite aware of the decline in the prevalence of malaria, there have been several papers on this since 2009 1,2 and still very recently2. But these are overall prevalence figures, some as parts of ongoing research projects, and others are based on variable data from national health reports. It would be nice to know how much of this is due to statistical variability and the focal nature of transmission, and how much is due to true interventions.
In the most case there are few if any epidemiologically designed evaluations of the impact of such interventions because the specific donor is more interested in getting nets and having them distributed than evaluating the effect.  Not wanting to cast aspersions, it would be useful to know what proportion of funds allocated to procure bednets are earmarked for monitoring and evaluation.  Data exist, but collecting such information and processing it for use requires training in epidemiology, something that is lacking in many NMCPs.
We have shown the value of this from our own work in Southern Province in Zambia.  We have been doing numerous cross-sectional and longitudinal studies on the case positivity rate in the Macha area, with prevalence rate during the years 2008 to 2012 calculated by randomization. However these results are not at all in concordance with incidence calculated from weekly RDT positivity incidence detected at local rural health centres where people go when ill, and malaria is diagnosed by RDT and the information transmitted by SMS to the staff at the Macha Research Station. During those periods case incidence rates in health centres have indicated that malaria is still being transmitted.
How much more important are the records from the rural health centres where people with malaria are likely to visit when unwell? Our perception and analyses suggest that weekly case incidence rates from these RHC give a clear picture of the general whereabouts of foci of transmission, particularly during the low transmission season3. This demonstrates the importance of detection of asymptomatic cases and definition of parasite reservoirs during these times of low transmission4,5.  This concept introduces a potential new strategy to detect transmission foci, particularly where past interventions have been successful in reducing transmission, and that will be to target interventions to eliminate these foci. Such a strategy could be integrated into the public health system, but will require specialized training in epidemiology and GIS – surely this could be directed to field vector biologists who one hopes will become part of the public health system.  It certainly would be better than purchasing more and more LLINs that will continue selection for pyrethoid resistance!  
The take home message from this can be summarized in point form:
As expected, widespread use of a single insecticide group has selected for resistance, hence the increasing problem of spreading populations of the highly endophilic mosquito, An. funestus
This is a major concern, and strategies to deal with this situation need to be developed. There is no point in just sending more nets. Careful evaluation needs to be done, alternative insecticides must be used, and if nets are not amenable to the compound, then IRS needs to be emphasized. 
Programmes need to be correlated with data on transmission foci, where and when they are vulnerable to attack and what tools can be used. Appropriately trained personnel need to be recruited, paid appropriately and integrated into the control system (NMCP)
There needs to be a method to coordinate activities, and donors need to agree to such coordination, because management across programmes is essential.
Reference List
(1) Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IR, Johnston GL et al. A new world malaria map: Plasmodium falciparum endemicity in 2010. Malar J 2011;10:378.
(2) Gething PW, Battle KE, Bhatt S, Smith DL, Eisele TP, Cibulskis RE et al. Declining malaria in Africa: improving the measurement of progress. Malar J 2014;13(1):39.
(3) Davis RG, Kamanga A, Chime N, Castillo-Salgado C, Mharakurwa S, Shiff C. Early detection of malaria foci for targeted interventions on endemic southern Zambia. Malaria Journal 2011;10:260.
(4) Stresman G, Kamanga A, Moono P, Hamapumbu H, Mharakurwa S, Kobayashi T et al. A method of active case detection to target reservoirs of asymptomatic malaria and gametocyte carriers in a rural area in Southern Province, Zambia. Malaria Journal 2010;9(1):265.
(5) Stresman G, Kobayashi T, Kamanga A, Thuma P, Mharakurwa S, Moss W et al. Malaria research challenges in low prevalence settings. Malaria Journal 2012;11(1):353.

Clive Shiff, M.Sc. Ph.D. : Born, bred and educated in Rhodesia and South Africa. I started work as a Tsetse-Fly entomologist after leaving University but after a couple of years in the deep bush, I joined the Ministry of Health in the Malaria and Bilharzia Research Laboratory to work on malaria. I was sent to Zambia (then Northern Rhodesia) as medical entomologist (Zambia and Zimbabwe were one country then under the Central African Federation), and later was transferred to Southern Rhodesia where the scientific programmes were concentrated.  I spent more than 20 years working on malaria and bilharzia, (schistosomiasis) in what is now Zimbabwe. Our malaria work was based on vector control with indoor residual spraying, and involved in mapping the homesteads of all people in the rural areas where the intervention was carried out. The spray teams were centrally controlled and supervised so that regular inspections were carried out and the mosquito populations regularly evaluated and where possible tested for susceptibility to the insecticide in use. Concurrently anti-malaria drugs were provided to the clinics and health centres and all clinical malaria was treated at no cost to the patient.  The programme was successful and malaria became absent from the major part of the country, a situation that was maintained until the late 1990’s.  Following the collapse of the Ministry of Health due to local corrupt government, malaria has returned and has become rampant again. I learned a great deal in this process and after moving to the US in 1979, and joining Johns Hopkins University in 1986 I had the opportunity to work in Tanzania in a USAID programme to test the efficacy of insecticide treated bed nets in the Bagamoyo area. Subsequently in 2003, though the establishment of the Johns Hopkins Malaria Research Institute, I was able to work in Zambia where I made many friends and my interest has spread to measuring malaria and studying the patterns of transmission in the Southern Province. I was one of the people that set up the Malaria Institute at Macha, and am still involved with the work there.
I have joined the Malaria World commentary group, and propose to bring topics of current importance to the attention of the entire MW community to stimulate thought and seek consensus as we continue to battle with this insidious disease.


William Jobin's picture
Submitted by William Jobin on

Hi Clive,

Having known you since 1963 in Southern Rhodesia, I am always grateful for your insight on control of malaria or any other tropical disease. Thanks for your latest column. I was waiting for someone else to comment first, but I guess that is what we all do - wait.

I know you are keen about African countries developing their own entomology and epidemiology capabilities, not only to do careful evaluation of the NMCP efforts, but also to develop their local expertise to plan future actions.

Recently I have done some statistical analyses that show the profitability of suppressing malaria for Africans. The return on investment is something like a $6 increase in the national economy for every dollar invested in suppressing malaria.

Realizing the incredible value of this, African countries might want to start making their own investments in the fight, since it will boost their national economy. What is particularly valuable about this increase is that it occurs directly to farmers working in subsistence agriculture, as they become more healthy and can raise more crops.

And I can see two foci in which the country might invest this increase in their economic productivity.

ONE: Permanent positions for Entomologists and Epidemiologists in the NMCP to carry out evaluation and strategy development. This is especially important as they need to react to the Resistance Treadmill and other crises related to faltering control efforts.

It would also give the leadership in the NMCP the ability to refine their national strategy to fit their national ecology and epidemiology. Currently they are forced to follow a One Size Fits All strategy from RBM and the PMI.

TWO: Permanent positions in the NMCP for spray-people to do the annual indoor spraying, who then can ditch swamps and maintain street drains in urban areas during the off season. This will gradually build up a national staff of skilled workers to deal with flood emergencies, as well as handle an everyday attack on anopheline breeding sites. And permanent, year-round positions will get much better people than temporary hires for a one or two month spray round.

Unfortunately the latest annual report of WHO on malaria shows that in the 21 countries now being assisted by the US Presidential Malaria Initiative in Africa, as the PMI funds started flowing, national funds were cut off, and probably used elsewhere. But to me it would make more sense for those national funds to be diverted into permanent staff positions in the NMCP as outlined above. This will also prepare each country for that day in the future when the international donors turn to some other interest.

This is a political agenda that folks in the NMCP should take up with the Minister of Health and national authorities.

Do you agree?


William Jobin Director of Blue Nile Associates

Clive Shiff's picture
Submitted by Clive Shiff on

Dear Bill, and all who pass this way!!!!!
thanks for the comments, methinks we have a separate problem to deal with in the situation you cover. The commitment of the local country to deal with malaria. I know there is some disagreement with me, but the solution to the finance deal lies in some pressure for the recipient government to accept agreed fiscal responsibility. Hence there needs to be a third party involved in the negotiations between a donor and the government to establish a formal agreement for acceptance and disbursements of the funds. I see this as a role for WHO. I think back to the situation in the 1950's in Rhodesia, when a formal agreement was signed between the Government and WHO, detailing the contribution from each. This was a 5-year commitment and each partner was held to their role. I do not see this as happening when there are several donors, each with their own agenda. This will lead to loopholes and there are plenty of rats to exploit this. The issue is If country X wants to embark on a malaria control intervention then there needs to be a joint agreement. Only should aid be given to such signatories. We are not the worlds conscience. (We being the consortia of donors)
These are my thoughts

Clive Shiff

William Jobin's picture
Submitted by William Jobin on

I like your idea Clive,

And I think of donors such as the US Presidential Malaria Initiative which is currently spending over $600 million per year in 21 African countries for malaria suppression. If the folks in the Malaria Initiative would gradually encourage the individual countries to Match the funding from the Malaria Initiative, it would eventually double the expenditures available for the fight.

I had proposed this long ago to the Malaria Initiative for oil-rich countries like Angola who have billions in funds coming in from oil sales, yet spend almost nothing on their own malaria control.

African countries could contribute those things they have in abundance, such as local personnel to run labs, spray crews, ditching, and community action.

It would be a great way to reverse the trend of decreasing resources we are seeing globally for malaria suppression. And I have presented evidence in my latest article in the Malaria World Journal that malaria suppression stimulates African economies, making it a good investment with a return of over $6 for every dollar spent.


William Jobin Director of Blue Nile Associates

Submitted by Clive (not verified) on

My comments follow the colleague who quoted a WHO vector Expert saying We do not have a handle on the number of LLIN's ...etc.
I agree, there are numerous donors with varied agenda's "distributing nets. In Zambia a while back I visited the District Medical Officer who said he had just received a shipment of ITN's but was unable to distribute them because there were explicitly for pregnant women and children <5! There is little proper planning, very little in the way of resources to monitor and evaluate. In fact few programmes are "owned" by the country. That is why I feel WHO should be given international support to oversee projects and to support signatory countries in manageing and monitoring the work. What worries me too is that pyrethroid resistance in An. funesutu is selecting in favour of this species, and An Funestus is an EXCELLENT vector

Submitted by Manuel Lluberas (not verified) on

Dear Clive:

You bring out a few good points. Forgive me for adding to your concerns. A person very high up in the organogram of WHO's Vector Control Working Group made a statement that left me and a few others perplexed. The comment was something to the effect of "We don't really have a handle on how many nets are actually in African homes or how many of them are in use." This left several of us a bit confused and may be confirming what you mentioned in your note. Not only there is no significant evaluation of their impact, most equate bed net distribution with use, yet these terms are nowhere close to be equivalent.