All posts by Bill Brieger

Women Making Malaria History

March is Women’s History Month and thus a time to examine the role of women in bringing an end to malaria. For many years studies at the household level have told us that women often lack the financial independence or social support to make important decisions about malaria treatment and prevention for themselves and their children. Furthermore, as WHO notes, “Gender norms and values … influence the division of labour, leisure patterns, and sleeping arrangements may lead to different patterns of exposure to mosquitoes for men and women.” As part of the solution to these problems, it is important to look at women role models in the fight against the disease – at women making malaria history.

One of these role models is Tu Youyou who became one of three scientists to win the 2015 Nobel Prize for medicine. Her work of over 40 years was virtually unknown to the outside world until then, but her study of artemisinin medicinal compounds has saved the lives of millions.

Moving from the lab to the community one can find role models who have broken role stereotypes. A few years ago President’s Malaria Initiative-funded Africa Indoor Residual Spraying (AIRS) project drew out attention to Maimouna Sanogo as a woman making a difference. She helped protect people in her country from malaria through her work as a supervisor on AIRS indoor residual spraying project in Mali. The AIRS project reported that, “As a woman in a leadership role, Maimouna is a trailblazer. In Mali, only 37% of women participate in the labor force, while participation is nearly double among Malian men (70%).”

Women have played crucial leadership roles in national malaria programs. Dr TO Sofola as Director of Nigeria’s National Malaria Control Program (NMCP, now National Malaria Elimination Program) guided the transition of case management policy to the use of artemisinin-based combination therapy, oversaw planning for the first massive national LLIN campaign, guided development of the World Bank Booster Program support, helped strengthen Nigeria’s first Global Fund Malaria Grants, and brought state level malaria control programs into the national strategy process. Women have also led NMCPs in Malawi, Kenya and other countries.

Dr Rose Leke, Emeritus Professor of Immunology and Parasitology, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Cameroon, was one of six people to be given the Kwame Nkrumah Scientific Award for Women in 2011.  Dr Leke explained the challenges facing women, “Science is still a challenging field for women to enter, and even more so in which to progress. At the university, I have seen many promising young women finish their studies and start jobs as assistants only to either get stuck in that position indefinitely or eventually leave to take care of their families. There just wasn’t the mentorship or financial support for research needed for them to be able to progress. It was an issue I really took to heart.” Therefore, Dr Leke and colleagues started the HIGHER Women Consortium in Cameroon. We provided training and mentorship to young women researchers.

Women in academics, research, government and front line programs have and continue to make history in the efforts to eliminate malaria. As Dr Leke’s example shows, these women leaders can make sure no one stands in the way of ensuring that the next generation of women scientists, managers and field workers make malaria history.

Modern Day St Patrick Needed to Drive out Snakes and NTDs

While St. Patrick, the Christian missionary supposedly rid Ireland of snakes during the fifth century A.D., “Nigel Monaghan, who has trawled through vast collections of fossil and other records of Irish animals, has found no evidence of snakes ever existing in Ireland.” The rest of the world, of course, does not rest as easily, and therefore, “On June 9th, 2017 WHO categorized snakebite envenomation into the Category A of the Neglected Tropical Diseases.”

The World Health Organization explains that, “Snakebite envenoming is a potentially life-threatening disease that typically results from the injection of a mixture of different toxins (“venom”) following the bite of a venomous snake. Envenoming can also be caused by having venom sprayed into the eyes by certain species of snakes that have the ability to spit venom as a defense measure.” The organization notes that our of over 3,000 snake species globally, 250 are medically important because of their harmful venom. These can be found in 160 countries.

In preparation for the World Health Assembly, “the 142nd session of the World Health Organization’s Executive Board has recommended a resolution on snakebite envenoming to the 71st World Health Assembly, setting the scene for its possible adoption in May 2018.” The resolution calls on all countries to take definitive steps to stop the death, disability and suffering that snakebite inflicts on many of the poorest and most vulnerable of the world’s people.

A recent WHO report notes that, “As for other neglected tropical diseases, estimation of global morbidity, disability and mortality due to snakebite envenoming is problematic.” Rough estimates of the burden of snakebite include –

  • 8 million to 2.7 million cases of snakebite envenoming per year
  • 81 000 to 138 000 deaths per year
  • 400,000 people a year face permanent disabilities, including blindness, extensive scarring and contractures, restricted mobility and amputation following   snakebite envenoming

Mapping is a first important step for countries attempting to tackle this neglected disease. Sri Lanka was able develop snakebite risk maps to identify snakebite hotspots and cold spots in the country. A national survey in India found that, “Snakebite deaths occurred mostly in rural areas (97%), were more common in males (59%) than females (41%), and peaked at ages 15–29 years (25%) and during the monsoon months of June to September.” Costa Rica is using geographical information systems to identify populations in need of improved accessibility to anti-venom treatment for snakebite envenoming.

As Jose Mar?a Gutierrez and colleagues stress, “the need for incorporation of the proposed snakebite initiatives within the general struggle against all the NTDs will result in a significant and more logistically efficient reduction of human suffering.” This can be accomplished by having snakebite become part of the existing unified strategy for several NTDs that, “simplifies drug distribution, reduces duplication, and lessens some of the demands on health systems and staff.”

Thus with a unified approach we can hope to drive out snakes, worms, and other parasites from the homes, communities and countries of those suffering from the neglected diseases of poverty.

The Monkey on the Back of Malaria Elimination

Concerning malaria elimination, “WHO grants this certification when a country has proven, beyond reasonable doubt, that the chain of local transmission of all human (emphasis added) malaria parasites has been interrupted nationwide for at least the past 3 consecutive years.” This target is challenging enough, but becomes more complicated when we consider that zoonotic transmission of malaria among monkeys and humans has been documented in Brazil and Southeast Asia. We cannot expect monkeys to sleep under bednets, so creative and realistic solutions are needed.

The Malaria Eradication Research Agenda (malERA) recognizes this problem. Plasmodium knowlesi, originally found in macaque monkeys in Southeast Asia has been dubbed the fifth human malaria due to its spread to people as deforestation has disturbed the habitat of the monkeys. In particular malERA addresses the challenge of understanding the upward trend of this malaria infection in that region and the need for better understanding of transmission dynamics and proper diagnosis.

The danger of P. knowlesi is heightened by difficulties in diagnosing it and distinguishing it from other malaria species. “Recently, the prevalence of human infection with a simian malaria parasite, P. knowlesi, has become an important issue in a wide area of Southeast Asia. The identification of this parasite by microscopy is very difficult because it resembles the P. malariae parasite. However, the symptoms caused by P. malariae and P. knowlesi are very different, with only P. knowlesi causing severe and life-threatening malaria” (Komaki-Yasuda et al.)

Reports from Brazil highlight another ‘simian hotspot.’ While P. Knowlesi represents monkey infections reaching humans, the opposite may have happened to establish a reservoir in the New World. “P. vivax lineages appearing to originate from Melanesia that were putatively carried by the Australasian peoples who contributed genes to Native Americans. Importantly, mitochondrial lineages of the P. vivax-like species P. simium are shared by platyrrhine monkeys and humans in the Atlantic Forest ecosystem, but not across the Amazon, which most likely resulted from one or a few recent human-to-monkey transfers.”  But looking even further back in natural history, Escalante and colleagues found, “compelling evidence that P. vivax is derived from a species that inhabited macaques in Southeast Asia.”

A recent study in this area found the worrying results that, “The low incidence of cases and the low frequency of asymptomatic malaria carriers investigated make it unlikely that the transmission chain in the region is based solely on human hosts, as cases are isolated one from another by hundreds of kilometers and frequently by long periods of time, reinforcing instead the hypothesis of zoonotic transmission.”

In Africa, Linda Duval and co-researchers, who found P. falciparum in blood samples from two chimpanzees belonging to two different subspecies, warn that, “If malignant malaria were eradicated from human populations, chimpanzees, in addition to gorillas, might serve as a reservoir for P. falciparum,”

It appears that the dynamics between monkeys, malaria and humans has a long history. Even once certified malaria-free countries face the threat of imported malaria from people crossing borders. Now we must recognize that the threat may already live within borders. So since existing malaria interventions to protect humans from malaria cannot be applied to monkeys, accelerated research on the genetics of the parasite and the mosquito is needed to prevent both primate groups from getting malaria.

New Fully Online Global Health Learning Programs at JHU

Continuing professional development has often been a challenge for people in the field. They may not be able to get study leave, but they do need advanced training in order to progress. The Johns Hopkins Bloomberg School of Public Health as started a new Online Programs for Applied Learning (OPAL) that offers completely online Masters and Certificate degrees.

The Department of International Health is Offering three Master of Applied Learning (MAS) and one Certificate covering global health. The Certificate can be completed in one year minimum and the MAS in two years minimum. More information on these programs can be obtained at the links below.

Malaria by the numbers: are the statistics real or are they a barrier to community involvement?

George Mwinnyaa grew up in a small village in Ghana, West Africa. “I witnessed the death of several people including my siblings and my father. I became a health volunteer and later a community health worker.” George presented at the Johns Hopkins University TEDx event on 10 March 2018. Below are excerpts from that talk focused on his experiences in malaria interventions in Ghana and reflects on numbers found in public health interventions and questions what these numbers really mean to community members on the ground. George is currently an MHS student studying infectious disease epidemiology at the JHU Bloomberg School of Public Health.


I have always been very skeptical with numbers, particularly numbers that indicate program accomplishments from the developing world. Whenever I see numbers reporting a problem such as the mortality relating to malaria, Pneumonia, or diarrheal diseases- it puzzles me because these are all diseases that have received great attention, and there have been many interventions implemented. Yet these problems still exist, and the question is why?

Today malaria is still among the top causes of infant mortality in many African countries, including Ghana, yet we have mosquito nets, coils, sprays, long sleeved shirts that have been circulating in the country for years……and sometimes I wonder: why?

Total funding for malaria prevention and control was 2.7 billion dollars in 2016. Between 2014-2016, 582 million nets were distributed, of which 505 million were distributed in Africa, yet the number of malaria cases increased from 211 million in 2015 to 216 million in 2016 (WHO-malaria fact sheet, 2017).

I was once a supervisor for the distribution of long-lasting insecticide treated nets in rural communities. The numbers driven world saw big numbers that showed that many pregnant women were not sleeping under mosquito nets and so the solution to solve the malaria problem was to give them mosquito nets.

First, they started out by selling the nets and people would not buy them, then they offered them free to pregnant women and that did not change anything, next they distributed to families in a household and that did not change anything, and finally they implemented what is known as the hanging of long lasting insecticide treated bed nets.

This time we went into a house with a hammer, nails and ropes, and families showed us their bedroom and we hung the net for them. And yet malaria still rules. What happened with the free bed nets is now widely reported across different countries in Africa.
What do the numbers we measure mean to the people they represent?

As an example, there was a man in a small fishing village with seven children. His biggest worry was how to get food for his family. So the world of numbers develops numbers-based interventions, numbers-driven solutions. Reporters found months after the family received the mosquito nets that no one in the family slept under the mosquito nets; instead the man had sown the nets together and used them for fishing to feed his family.

Frustrations abound on both ends of the system, for public health agents and community members. Numbers act as the barrier between the two ends of the “system”, and our goal must be to break the barrier. The numbers that drive interventions can be meaningless to the community people they represent unless we engage the community and learn how our interventions can really help them.

World Hearing Day and the Problem of Infectious and Tropical Diseases

March 3rd marks the annual World Health Day. The World Health Organization explains that the purpose of this day is to raise awareness on how to prevent deafness and hearing loss and promote ear and hearing care across the world. WHO notes that, “Unless action is taken, by 2030 there will be nearly 630 million people with disabling hearing loss.”

Factors associated with health loss and disability include ageing of the population, environmental noise exposure, certain medications, and infectious diseases. It is the latter that we address here.

Globally there are several infectious diseases associated with hearing loss. In children these include congenital rubella infections a direct result of bacterial meningitis infections, although with improved immunization rates these are less of a problem. In contrast Congenital cytomegalovirus infection has been on the increase.

Continuing study of Ebola, Lassa Fever and Zika point to infectious tropical diseases as another serious concern.  The large scale of infection and survisorship in Ebola outbreak in West Africa made it possible to study on a large scale reported symptoms of “post-Ebolavirus disease syndrome” (PEVDS) that include, “chronic joint and muscle pain, fatigue, anorexia, hearing loss, blurred vision, headache, sleep disturbances, low mood and short-term memory problems.” A study of 277 Ebola Survivors in one Sierra Leone community found the following clinical sequelae were common: arthralgias (76%), new ocular symptoms (60%), uveitis (18%), and auditory symptoms (24%).

Lassa Fever has unfortunately made a strong showing in West Africa this dry season. Mateer and colleagues noted an association between Lassa fever (LF) and sudden-onset sensorineural hearing loss (SHNL) was confirmed clinically in 1990. Their literature review found that, “Although LF-induced SNHL has been documented, the prevalence and economic impact in endemic regions may be underestimated.”

Finally, while much of the focus on the complications of Zika have focused on microcephaly, other problems occur.  Zare Mehrjardi et al. documented that Zika Virus may cause “other central nervous system abnormalities such as brain parenchymal atrophy with secondary ventriculomegaly, intracranial calcification, malformations of cortical development (such as polymicrogyria, and lissencephaly-pachygyria), agenesis/hypoplasia of the corpus callosum, cerebellar and brainstem hypoplasia, sensorineural hearing-loss, and ocular abnormalities as well as arthrogryposis in the infected fetuses.”

The benefits of vaccines for rubella and meningitis should spur on immunization research for Ebola, Zika and Lassa Fever. In the meantime there are some preventive measures. One would not have thought that using personal protective equipment by health workers would protect hearing, but it is a practice that should be enabled and encouraged for multiple reasons. Household and community control of Aedes aegypti and rodent breeding to prevent Zika and Lassa, respectively, can also help. By protecting our communities from infection we can also protect their hearing.

The Heart of the Malaria Problem

February is Heart Month in some countries. This is a good time to explore how malaria affects the heart and cardiovascular health.

In 1946 Howard Sprague observed that although “malaria is a disease from which no organ or tissue is exempt, this paper is concerned with its influence upon the circulation, and more particularly upon the heart itself.” He then outlined four ways by which this influence happens:

  1. its chronic and recurrent nature
  2. the systemic toxemia of the paroxysm
  3. the profound anemia produced by hemolysis and suppression of hemopoiesis
  4. the occlusion of capillaries and arterioles of the myocardium

Since that time other researchers have elaborated on malaria and the cardiovascular system.

Mishra et al. raise a concern that, “The role of the heart in severe malaria has not received due attention.” They point out the following:

  • hypotension, shock and circulatory collapse observed in severe malaria patients
  • raised cardiac enzymes in complicated malaria
  • compromised microcirculation and lactic acidosis as well as excessive production of pro-inflammatory cytokines
  • Intravascular fluid depletion associated with severe malaria leading to impaired microcirculation … among others

They conclude that “Sudden cardiac deaths can also occur due to cardiac involvement,” but worry that, “It is not feasible to assess the cardiac indices in resource poor settings.”

A study by Ray and co-researchers indicated “involvement of cardiovascular system in severe malaria as evidenced from ECG and echocardiography. The study also revealed that cardiovascular instabilities are common in falciparum malaria, but can also be observed in vivax malaria.” A fatal case of imported malaria where the sole finding revealed at the postmortem evaluation was an acute lymphocytic myocarditis with myocardiolysis was described by Costenaro and colleagues.

In another example, Onwuamaegbu, Henein, and Coats reviewed the potential role of malaria in chronic and severe malaria and the connection to chronic heart failure. They concluded that, “Our review of the literature suggests that there are significant similarities in the cachexia seen in CHF and that of malaria, especially as related to the effects of muscle mass and immunology.” Clinical manifestations in P. falciparum malaria also include reduced cardiac output as was reported in an imported case of malaria by Johanna Herr and co-workers.

Marrelli and Brotto note that, “Sequestration of red blood cells, increased levels of serum creatine kinase and reduced muscle content of essential contractile proteins are some of the potential biomarkers of the damage levels of skeletal and cardiac muscles.” They explain that, “These biomarkers might be useful for prevention of complications and determining the effectiveness of interventions designed to protect cardiac and skeletal muscles from malaria-induced damage.”

Not just malaria as a disease is involved, but also the medicines used to treat it. Ngouesse and colleagues draw attention to antimalarial drugs with cardiovascular side effects. They draw particular attention to the dangers of halofantrine, quinine and quinidine, but also note mild and/or transient effects of other antimalarials.

Guidelines exist for proper and prompt malaria case management, especially protocols for caring for patients with severe malaria. These and the medicines required must be more readily available to front line health staff. And of course is we are more diligent in preventing malaria through long lasting insecticide-treated nets and other measures, our worries about severe malaria and CVD complications will reduce.

Malaria Should Lead to Compassion, Not Hate

In August 2017 the ‘Almost Impossible’ happened decades after the last of local malaria transmission stopped in Italy. NPR shared news from the Italian newspaper Corriere della Sera that, “A 4-year-old girl has died of malaria in Italy, where the disease is thought to have been wiped out. Troubled health officials are looking for answers.” By coincidence, two children from an African nation were being treated for malaria in the same hospital where the deceased was being treated for diabetes. No epidemiological link could be found.

World Malaria Report:

Unfortunately that has not stopped anti-immigrant politicians from using the incident to foster hatred.  The political party of a “far-right extremist who wounded 6 African immigrants in a racially motivated shooting rampage in central Italy,” blamed the death of the child mentioned above “from malaria on migrants who ‘bring back to Europe’ once, eradicated illnesses.”

A new article in Malaria Journal reports that even though, “Malaria is no longer endemic in Italy since 1970 when the World Health Organization declared Italy malaria-free, … it is now the most commonly imported disease.”  The study from Parma, Italy reports that, “Of the 288 patients with suspected malaria, 87 were positive by microscopy: 73 P. falciparum, 2 P. vivax, 8 P. ovale, 1 P. vivax/P. ovale, 1 P. malariae and 2 Plasmodium sp. All samples were positive by ICT except 6. ”

Malaria can travel with anyone who has been in an endemic area, whether migrant,  tourist or business person. The likelihood of malaria re-establishing itself in currently non-endemic areas is low, but there is of course value in maintaining epidemiological and entomological surveillance world-wide in the current drive to eradicate the disease.

The identification of malaria anywhere in the world should be cause for concern and compassion, not hate and exclusion.

African Leaders Malaria Alliance Recognizes Country Achievements, Adds NTDs to its Scorecard

The 30th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

Climate Changes Many Things Including Malaria

Heavy rains, flooding and malaria

A changing climate, even a warming climate, does not directly translate into greater malaria transmission.[i] Lafferty and Mordecai explain that we need a need “a greater appreciation for the economic and environmental factors driving infectious diseases,” as these have their own impact on transmission.[ii] Climate change effects occur in parallel to “changes such as land conversion, urbanization, species assemblages, host movement, and demography.” This wider ecological understanding is needed to “predict which diseases are most likely to emerge where, so that public health agencies can best direct limited disease control resources.”

As the WHO framework for malaria elimination stresses, [iii] “Most countries have diverse transmission intensity, and factors such as ecology, immunity, vector behaviour, social factors and health system characteristics influence both the diversity of transmission and the effectiveness of tools, intervention packages and strategies in each locality.”8 The Framework goes further to encourage strategic planning and interventions appropriate for the diverse settings or strata within a country. What climate change implies is that the nature of malaria transmission in these strata will change as temperature, rainfall, humidity and human response change. Countries not only need to adapt malaria activities to existing strata, but also be alert to changes in transmission and thus changes needed in strategies.

Increased or decreased vector control activities would be one example of changes that are needed in response to climate, vector habitat and transmission changes. “The receptivity of an area (to vector control interventions) is not static but is affected by determinants such as environmental and climate factors.” Case detection will become even more crucial as transmission drops and the success of elimination programs depends on identifying, tracing and responding to remaining cases promptly and accurately.

The landscape for malaria control and elimination is shifting in part because of the success of interventions since the dawn of Roll Bank Malaria in 1998.  As we have shown here, there may also be shifts due to climate change. Of great concern is the shifts that expose new and more vulnerable populations, such as those in the East Africa highlands to the threat of malaria. National Malaria Programs need strong surveillance efforts that monitor disease, vectors and climate, and be ready to respond.

[Excerpted from Africa Health]

[i] World Health Organization. Climate change and health. Fact sheet. Updated July 2017.

[ii] Lafferty KD, Mordecai EA. The rise and fall of infectious disease in a warmer world. F1000Research 2016, 5(F1000 Faculty Rev):2040 last updated: 19 AUG 2016. (doi: 10.12688/f1000research.8766.1).

[iii] Global Malaria Program. A framework for malaria elimination. World Health Organization 2017, ISBN 978-92-4-151198-8.