The tragedy is that the vast majority of the morbidity and mortality due to malaria are preventable. While the burden is great, the promising news is that there are evidence-based interventions proven to prevent and manage malaria infection.

Malaria prevention and control during pregnancy has a three-pronged approach:

i) Intermittent preventive treatment;
ii) Insecticide-treated nets; and
iii) Case management of malaria illness.
 

Combating malaria among children focuses on:

i) Insecticide-treated nets; and
ii) Case management of malaria illness.

Intermittent Preventive Treatment (IPTp)
IPTp involves providing all pregnant women—even if they do not show symptoms of malaria—with at least two preventive treatment doses of an effective antimalarial drug (currently sulphadoxine-pyrimethamine [SP]), during routine antenatal clinic visits beginning in the second trimester. Recognizing that at least 70% of pregnant women in malaria endemic countries in sub-Saharan Africa attend antenatal care services at least once during pregnancy, focused antenatal care has been shown to be a safe, inexpensive and effective platform to deliver IPTp. A study in Malawi evaluating IPTp showed a decline in placental infection (32% to 23%) and in the number of low birth weight babies (23% to 10%). It also found that 75% of all pregnant women took advantage of IPTp when offered. IPTp has also been shown to substantially reduce the risk of anemia in pregnant women. The remaining challenge is ensuring that pregnant women receive focused antenatal care early in pregnancy to have access to at least two doses of IPTp during their pregnancy.

Insecticide Treated Bed Nets (ITNs)
Mosquito nets, if properly used and maintained, can provide a physical barrier to hungry mosquitoes, which mostly bite at night. If treated with insecticide, the effectiveness of nets is greatly improved, generating a chemical halo that extends beyond the mosquito net itself. This tends to repel or deter mosquitoes from biting or shorten the mosquito’s life span so that she cannot transmit malaria infection.
ITNs have been proven to decrease both the number of malaria cases and malaria death rates in pregnant women and their children. A study in an area of high malaria transmission in Kenya has shown that women protected by ITNs every night during their first four pregnancies produce 25% fewer underweight or premature babies. In addition, the use of ITNs benefits the infant—who sleeps under the net with the mother—by decreasing exposure to malaria infection. ITNs should be provided to pregnant women as early in pregnancy as possible, and their use should be encouraged for women throughout pregnancy and during the postpartum period. Health education programs, access to and promotion of ITNs through antenatal care, social marketing and lobbying to reduce the prices of ITNs and re-treatments are all helping to encourage their use by pregnant women.

Trials of insecticide-treated nets (ITNs) in the 1980s and 1990s showed that ITNs reduced deaths in young children by an average of 20%. Unfortunately, ITNs can be expensive for families at risk of malaria, who are among the poorest in the world. In addition, until people are in the habit of using ITNs, many need to be convinced of their usefulness. Until recently, ITNs also needed to be re-treated with insecticide every 6-12 months, which proved to be extremely difficult to sustain. The recent development of long-lasting, wash-resistant ITNs—which remain effective for up to five years—is diminishing the need to re-treat nets on a consistent basis.

Integrated Community Case Management
Community case management (CCM) is a strategy to deliver life-saving, curative interventions for common childhood illnesses such as malaria, particularly in areas where access to facility-based services is low. Experts agree that 60% of the 9.7 million children who die annually could be spared if we just delivered the life-saving interventions that we already have to families that need them most. These interventions include:

• Antibiotics for pneumonia, dysentery and newborn sepsis;
• Antimalarials; and
• Oral rehydration packets and zinc supplements for diarrhea.

Unfortunately, the use of these interventions is low in most developing countries because the services that deliver them are inaccessible, not available, of poor quality, and/or not demanded.

Preventive interventions can be electively scheduled. Curative interventions, on the other hand, must be continuously available as children acquire infections unpredictably and can rapidly deteriorate and die without treatment. Hundreds of millions of people in developing countries, especially those in rural areas, live beyond the reach of facilities, which only treat a small fraction of sick children. While preventive interventions are essential, they are an incomplete solution as their use and effectiveness will be imperfect. Therefore, curative services must remain a mainstay of disease control for the foreseeable future.

CCM strategies support Ministry of Health (MOH) partners to train community health workers (CHW) to assess, classify, treat, counsel and, if feasible, refer children with signs of infection. CHWs are also trained to support, supervise and supply workers, and to train families to recognize and seek care for signs that indicate serious disease.

Intermittent Preventive Treatment for Infants
WHO has set in motion the process of approving Intermittent Preventive Treatment for infants (IPTi) as an additional tool for malaria control. Ghana has adopted this strategy based on its inclusion among 19 countries where the IPTi Consortium tested the efficacy and safety of this approach. The IPTi Consortium found that IPTi delivery can feasibly be part of routine child immunization and recommends this platform. MCHIP is well placed to apply its extensive experience in IPTp policy development, capacity development, and performance quality improvement approaches to ensure IPTi implementation is successfully integrated into routine child health services, just as IPTp is integrated into routine ANC.

Community Engagement
Engaging communities to address malaria is a critical component for effective prevention and control. Communities are at the forefront of healthcare promotion and services for women, newborns and children. Their participation in malaria prevention and control accelerates malaria programming, especially for the most vulnerable groups. Supporting local organizations in program design, monitoring, implementation and evaluation is a cornerstone of these efforts. The President’s Malaria Initiative’s Malaria Communities Program (MCP) is leading these efforts in 12 countries.