Fears of a malaria relapse in Madagascar

Madagascar’s recent gains in the battle against malaria are likely to be reversed because funding problems have interrupted prevention activities.

“When fighting malaria, you need to be very technical. When grants come in too late, we end up handing out nets and spraying houses during the rainy season. There are many remote places, which we can’t reach during this time,” Benjamin Ramarosandratana, director of the National Programme for the Fight Against Malaria, told IRIN.

“This year, our 2012 funding came in months later than we expected. For the next campaign, which runs from 2013 until 2015, we haven’t even signed the contract yet, while the year is already half over. This means that the nets we wanted to distribute in August won’t arrive until November,” Ramarosandratana said.

“Fighting malaria is like sitting on a spring. You need to keep up the pressure to keep figures low. The moment you let go, the amount of cases soar,” he said.

"Fighting malaria is like sitting on a spring. You need to keep up the pressure to keep figures low"

Donors suspended all but emergency assistance to Madagascar in 2009, after President Marc Ravalomanana was deposed in a coup d’etat.

Slow bureaucratic procedures and the long-running political crisis have increased the country’s poverty levels. “With more than 92 percent of the population living under US$2 a day, Madagascar is now one of the poorest countries in the world,” the World Bank said in a 5 June briefing. These factors have combined to disrupt large-scale antimalarial campaigns. 

The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US-based President’s Malaria Initiative (PMI) saw external funding for malaria prevention in the country increase between 2005 and 2011, peaking at US$96 million in 2010. But since 2012, funding glitches have become a major concern.

Pockets of malaria

Between 2007 and 2011, about $240 million was spent by a variety of donors on malaria control, including indoor residual spraying (IRS), distributing insecticide-impregnated mosquito nets, and training health workers on the use of rapid diagnostic test (RDTs) kits.

More than 8.2 million nets were distributed in high-transmission areas in 2009 and 2010. As a result, 92 percent of the at-risk population was covered by either nets or IRS, according to the 2011 Malaria Indicator Survey. The prevention campaign resulted in a 13-fold reduction in reported malaria morbidity at primary health centres, from 130 cases per 1,000 people in 2003 to 10 per 1,000 people in 2011, according to government figures.

IRS is seen as a key tool in malaria prevention, and was scaled up to reach over 1.8 million households annually between 2010 and 2012. But funding shortages will cause a 70 percent reduction in IRS in 2013.

There is concern the disease is establishing footholds in remote areas, which could lead to malaria spreading to more populous areas.

One such foothold is Ankazobe, in Analamanga District, where 19 people died of malaria in February. Ankazobe last received mosquito nets in 2010; the nets were scheduled to be replaced this year, but new nets did not arrive.

Increasing insecurity in the south has also prevented malarial spraying campaigns across eight communes and several rural districts. “There were so many dahalos [bandits] in the area, that it would have been suicide to go there,” Ramarosandratana said. 

“The human factor”

Even when grants for antimalarial strategies are received on time, the fight against the disease is complicated by what Ramarosandratana calls “the human factor.”

“When you go back to a [net] distribution place three months later, you sometimes see that the percentage of households that own a net has dropped from 80 to 60 percent,” Ramarosandratana said. “Poverty is our big enemy here. Sometimes people don’t use the net but keep it safely wrapped up in their house, or they sell it on the market.”

"Poverty is our big enemy here. Sometimes people don’t use the net but keep it safely wrapped up in their house, or they sell it on the market"

In the southeastern, malaria-prone village of Ranomafana, few households possess mosquito nets, even though there is a distribution programme and all pregnant women receive them for free at the antenatal clinic.

“They gave us three free nets two years ago, but my grandchildren played with them and broke them all when I was working in the field,” said Justine Ravao, 55.

Net use is also thought to have declined when the disease was receding; a malaria outbreak in the southern Vatovavy-Fitovinanay, Atsimo Atsinanana and Androy districts last year was seen as a consequence of this.

“Some community members started to use the nets on their beds, to protect themselves from fleas, but as soon as they stopped using them correctly, they were vulnerable when we had a malaria resurgence,” PMI malaria specialist Alyssa Finlay-Vickers told IRIN.

“We need new tools and technology. The impregnated bed nets don’t last as long as we thought they would, and distributing millions of nets every three years to protect the population may be difficult to sustain,” she said.

Preventing drug resistance

“To think we can eradicate, or even eliminate, malaria in Madagascar is believing in utopia. The conditions here are too favourable for these mosquitoes to breed. The only thing we can do is fight the malaria mortality rates,” Ramarosandratana said.

"When I was young, they used to distribute nivaquine like candy. It takes about a decade before the malaria drugs don’t work any longer"

“Malaria is easy to treat, but the problem with it is that it comes back. A child can have up to four malaria attacks a year,” Ramarosandratana continued. About 17,000 community health workers have been trained to use RDTs and provide first-line malaria treatment, he said. But overtreatment can cause drug resistance.

“When I was young, they used to distribute nivaquine like candy. It takes about a decade before the malaria drugs don’t work any longer,” said Clement Ranoeliharivelo, a general practitioner at Fondation Médical d'Ampasimanjeva, a hospital in Vatovavy-Fitovinany Region.

“The problem is self-medication. In the 80s, nivaquine was sold in every small epicerie [small grocery stores] in the country. People took incorrect doses, and now the medicine has become useless. The medicine we have now is the last one we have. If the malaria parasites build resistance against this, we won’t know what to do next,” Ramarosandratana said.

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