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Situational analysis

Epidemiology
Interventions
Indoor Residual Spraying

Epidemiology

It is estimated that 1 million people are killed annually from malaria.1 A multiple of people experience an episode of malaria, which reduces quality of life and economic productivity, which makes malaria in important contributor to poverty.

In Malawi 250,000-300,000 cases of malaria are reported in health facilities monthly.2 Adults lose an average of 25 working days per year, which results
 in significant loss of household income. In addition, the cost of treatment can easily overwhelm family resources in Malawi where low-income families spend an estimated 28% of their yearly income to treat malaria.

The under-five mortality rate in Malawi is 125 per 1000, which is the 33rd highest in the world4.  Malaria is the most frequent cause of morbidity and mortality in Malawian children under five years of age and is the cause of over 40% of deaths in children under two.  Children under-five suffer on average 9.7 malaria episodes per year, while adults suffer 6.1 such episodes.  

Pregnant women are at particular risk of malaria infection. The maternal mortality ratio is 980 per 100,000 live births. In mothers malaria results in anemia and fever. Malaria affects the placental function and increases the risk of still birth and low birth weight significantly.

Nkhoma Hospital treats annually 16,726 cases of malaria. 59% of cases are under 5 children. The number of new cases is highest in the rainy season (November-April) with a peak in January (Figure 1). The outpatient department and laboratory of the hospital are extremely busy during that period. 160 patients die annually of malaria. 68% of fatal cases are children (Figure 2). Malaria is an important cause of severe anaemia in children. In January 2007 125 blood transfusions were performed in the pediatrics ward versus 12 in August 2007.  

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Interventions

The Roll Back Malaria (RBM) campaign of the World Health Organisation recommends four key strategies for malaria control in stable endemic area's.

Table 1: RBM key strategies for stable endemic area's

These strategies have been included in the Strategic Framework of the National Malaria Control Program 2005-2010.

Nkhoma Hospital provides primary health care to a catchment population of  60,490. The population counts 10,283 under 5's and 3,024 expected pregnant annually (table 1). The hospital distributes ITN's in the antenatal care and <5 program. The hospital distributes approximately 2500 nets to pregnant women and 2600 nets to <5 children annually. The Health Surveillance Assistants conduct an annual retreatment campaign in the catchment area of the hospital. The hospital treated 16,726 cases of laboratory confirmed malaria (thick slide) in 2008.  The first line regimen is Artemisinin Combination Therapy. The hospital has a service level agreement with the District Health Office (DHO) Lilongwe for free antenatal and delivery care since 2006 and recently signed a service level agreement for <5 care. The <5 service level agreement has resulted in a siginificant increase in the in- and outpatient care for children.

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Indoor residual spraying in Malawi

The malaria strategy 2005-2010 included a plan for introducing IRS as a malaria prevention strategy in rural Malawi. It specified the implementation of an IRS pilot to document operational, logistical and human resource requirements for IRS scale-up in rural Malawi, which was implemented in part of the Nkhota Khota district by Nkhota Khota DHO in collaboration with RTI International.

The Nkhota Khota pilot study observed a significant decrease in the case load and malaria mortality in the intervention area. The health centre on the Ilovo estates saw a reduction of 30%  after IRS was introduced in 2001 and a further case reduction of 27% after IRS was implemented in the surrounding area. The vector density of Anopheline mosquitoes was significantly reduced in the months in the intervention of the NkhotaKhota pilot study.5

In line with the concept of Integrated Vector Management (IVM) and the experience gained with the pilot projects the Government of Malawi released 'Guidelines for Indoor Residual Spraying in Malawi' in 2008 and committed itself to “seriously embark on IRS in the country” (citation from foreword by Hon. Khumbo Kachali, MP, Minister of Health).

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