Category Archives: Indoor Residual Spraying

Initial Evidence Of A Reduction In Malaria Incidence Following Indoor Residual Spraying With Actellic 300 Cs In A Setting With Pyrethroid Resistance: Mutasa District, Zimbabwe

Mufaro Kanyangarara and her PhD thesis adviser, Luke Mullany of the Johns Hopkins Bloomberg School of Public Health Department of International Health, have been looking into the challenges of controlling and eventually eliminating malaria in a multi-country context in southern Africa. We are sharing abstracts from her pioneering work including the following which explores indoor residual spraying in Zimbabwe in a District near the Mozambique border.

sprayed and unsprayed wardsIn order to reduce the vector population and interrupt disease transmission, IRS with appropriate insecticides is essential. In response to local vector resistance, the Zimbabwe NMCP with support from PMI began a large-scale IRS campaign with organophosphates in four high transmission districts in Manicaland province – Chimanimani, Mutare, Mutasa and Nyanga. Using HMIS data, the present study reports on the effect of switching from pyretheroids to OP on malaria morbidity in one of the four high transmission districts selected. In the subsequent high transmission season following the switch from pyretheroids to organophosphates, there was evidence of a 43% decline in malaria incidence reported by health facilities from wards in Mutasa District treated with organophosphates, after accounting for possible confounding by environmental variables. Previous research shows that switching to organophospates effectively reduced biting rates and vector densities in areas with pyretheroid resistant strains in Ghana, Benin and Tanzania. Although previous research focused on using entomological data to show the reduction in the vector population following application of Actellic, organophosphates, this study adds to the literature by showing a decline in malaria transmission using health facility surveillance data.

In the present study, there were variations in rainfall and temperature over the study period, and these changes were associated with changes in malaria incidence. The study results also indicated malaria transmission in Mutasa District was driven by rainfall, proximity to second order streams, elevation and temperature. These results concur with previous research, which found that elevation, temperature, and rainfall are positively associated with malaria incidence. After adjustment for climatic variables and seasonality, malaria incidence rates a downward trend following the 2014 IRS campaign and thus supporting the plausible conclusion that switching to organophosphates in this setting contributed to the observed public health benefits. No major political, socio-economic, or health-care changes with the potential to reduce malaria morbidity by almost half occurred in Mutasa District during the study period.

Observed and predicted weekly malaria counts in MutasaTypically data from health facilities only includes data on the number of suspected cases. The HMIS in Zimbabwe is more sophisticated in that it allows reports of confirmed malaria cases. In calculating of incidence rates, the denominator used was the catchment area population size. The reliability of this value has been questioned as this assumes that people will visit the closest health facility/health facility in their catchment area. It is noteworthy to mention that in the present study the main results did not chance after including an offset for catchment area population size. This indicates that in the Zimbabwean context, the reported catchment area population size may be a reliable estimate. The study also underscores the utility of HMIS data in the evaluation of population level interventions. The HMIS has the advantage of providing quality data quickly and easily, with minimal additional investment. Additionally, HMIS reflects the burden of disease on the health system. Results from this study further suggest that passive surveillance data from the HMIS in Zimbabwe was sufficiently sensitive to detect IRS related reduction in malaria morbidity among residents of Mutasa District.

There are several important limitations of this study that should be highlighted. Causal inferences between spraying and improvements in malaria incidence should be made with caution as spraying was not implemented as an intervention in a randomized control trial. However, data from 14 health facilities located in unsprayed wards were included in the analysis to serve as a comparison and help understand any possible changes in malaria morbidity unassociated with the 2014 IRS campaign. Although the univariate model indicated that health facilities in unsprayed wards carried a lower burden of malaria, the multivariable model showed no significant differences between health facilities in sprayed and unsprayed wards prior to the IRS pilot, suggesting that climatic variables included in the model adequately adjusted for differences. However, it should be noted that although the study adjusted for environmental factors, it did not account for other factors like population movement, changes in treatment seeking behaviors, changes in the coverage of ITNs during the study period. The model developed in this analysis assumed that these factors remained constant over the study period. This seems reasonable given that the rural population of Mutasa is relatively stable, with access to health facilities providing malaria diagnosis and treatment. Additionally, although the number of suspected malaria cases was not explicitly model, a descriptive analysis does not indicate changes in diagnostic practice over the study period (data not shown). The HMIS in Zimbabwe has been in place for decades and has previously been used to evaluate the impact of changes in malaria morbidity, construct empirical seasonality maps and describe the spatial and temporal distribution of malaria.

Despite these potential limitations, health surveillance systems provide a feasible and efficient means of collecting longitudinal data on measures of malaria morbidity. The pronounced decline in malaria morbidity observed in this study is evidence supporting the benefit of switching to an insecticide class with a different mode of action in response to pyretheroid resistance. Although the IRS strategy implemented by ZNMCP and PMI was successful, continued entomological monitoring will be necessary. Additionally, with emerging resistance to multiple insecticides, this approach may not be sustainable over time. There is need for the development of novel strategies to manage insecticide resistance.

Moving toward Malaria Elimination in Botswana

elimination countriesThe just concluded 2015 Global Health Conference in Botswana, hosted by Boitekanelo College at Gaborone International Convention Centre on 11-12 June provided us a good opportunity to examine how Botswana is moving toward malaria elimination. Botswana is one of the four front line malaria elimination countries in the Southern African Development Community and offers lessons for other countries in the region. Combined with the 4 neighboring countries to the north, they are known collectively as the “Elimination Eight”.

The malaria elimination countries are characterised by low leves of transmission in focal areas of the country, often in seasonal or epidemic form. The pathway to malaria elimination requires that a country or defined areas in a country reach a slide positivity rates during peak malaria season of < 5%.

pathwayChihanga Simon et al. provide us a good outline of 60+ years of Botswana’s movements along the pathway beginning with indoor residual spraying (IRS) in the 1950s. Since then the country has expanded vector control to strengthened case management and surveillance. Particular recent milestones include –

  • 2009: Malaria elimination policy required all cases to be tested before treatment malaria elimination target set for 2015
  • 2010: Malaria Strategic Plan 2010–15 using recommendations from programme review of 2009; free LLINs
  • 2012: Case-based surveillance introduced

The national malaria elimination strategy includes the following:Map

  • Focus distribution LLIN & IRS in all transmission foci/high risk districts
  • Detect all malaria infections through appropriate diagnostic methods and provide effective treatment
  • Develop a robust information system for tracking of progress and decision making
  • Build capacity at all levels for malaria elimination

Botswana like other malaria endemic countries works with the Roll Back Malaria Partnership to compile an annual road map that identifies progress made and areas for improvement. The 2015 Road Map shows that –

  • 116,229 LLINs distributed during campaigns in order to maintain universal coverage in the 6 high risk districts
  • 200,721 IRS Operational Target structures sprayed
  • 2,183,238 RDTs distributed and 9,876 microscopes distributed
  • While M&E, Behavior Change, and Program Management Capacity activities are underway

Score cardFinally the African Leaders Malaria Alliance (ALMA) provides quarterly scorecards on each member. Botswana is making a major financial commitment to its malaria elimination commodity and policy needs. There is still need to sustain high levels of IRS coverage in designated areas.

Monitoring and evaluation is crucial to malaria elimination. Botswana has a detailed M&E plan that includes a geo-referenced surveillance system, GIS and malaria database training for 60 health care workers, traininf for at least 80% of health workers on Case Based Surveillance in 29 districts, and regular data analysis and feedback.

M&E activities also involve supervision visits for mapping of cases, foci and interventions, bi-annual malaria case management audits, enhanced diagnostics through PCR and LAMP as well as Knowledge, Attitudes, Behaviour, and Practice surveys.

Malaria elimination activities are not simple. Just because cases drop, our job is easier. Botswana, like its neighbors in the ‘Elimination Eight’ is putting in place the interventions and resources needed to see malaria really come to an end in the country. Keep up the good work!

Indoor Residual Spraying – not a one-trick pony

Jasson Urbach and Donald Roberts claim that the malaria fight is hurt by flimsy anti-DDT research as they opine in Business Day (South Africa) on 9th May 2014. They are particularly exercised by an article on possible DDT effects on bird egg shells. Despite the controversy sparked by the article, there is no evidence that any individual country nor WHO itself is recommending removal of DDT from the arsenal of chemicals used in indoor residual spraying (IRS) to control malaria.



There is something about DDT that raises hackles among proponents and detractors. But malaria vector control planners do have choices. WHO recommends 14 insecticides for indoor residual spraying against malaria vectors as seen below in an list updated on 25 October 2013:

  1. DDT
  2. Malathion
  3. Fenitrothion
  4. Pirimiphos-methyl
  5. Pirimiphos-methyl
  6. Bendiocarb
  7. Propoxur
  8. Alpha-cypermethrin
  9. Bifenthrin
  10. Cyfluthrin
  11. Deltamethrin
  12. Deltamethrin
  13. Etofenprox
  14. Lambda-cyhalothrin

Ironically DDT tops the list.  No chemical is 100% safe, so the caveat with any of these chemicals is that, “WHO recommendations on the use of pesticides in public health are valid ONLY if linked to WHO specifications for their quality control. WHO specifications for public health pesticides are available on the Internet.

Interestingly, a bigger concern should be the potential for mosquitoes to develop resistance to any of the above mentioned insecticides.  This is why it is important to avoid putting all our eggs – soft or hard shelled – in one basket. Ideally insecticides should be rotated often to prevent resistance from developing.

Decisions to embark on IRS and choice of insecticides should be based on national and sub-national environmental and epidemiological characteristics, not emotional attachment to any particular product.

Nigerian Lawmakers Skeptical at Time When More National Malaria Support Needed

mip-nigeria-sm.jpgAs global financial support for malaria and other disease control efforts has faltered, there is a greater need for national malaria programs to pick up the slack. A look at Nigeria’s national health accounts does show that ‘foreign’ aid does play a relatively small role in health financing and expenditure in this oil-rich country, but ironically it is the common citizen who picks up the bulk of health financing through out-of-pocket expenditures.

The question of local initiative in the move toward elimination of malaria received a severe blow when the Nigerian Senate Committee on Health questioned the need for continued purchases of long lasting insecticide-treated nets (LLINS). The Guardian newspaper reported that the, “Chairman of the committee, Dr. Ifeanyi Okowa, wondered why Nigeria would still continue to cling to the strategy, which he said was not working, when country like Senegal that has manufacturing plants for LLINs was using other effective means to tackle malaria.”

The Senator’s views contrast with those of national experts and the WHO: “While the Minister of State for Health, Dr.Muhammad Ali Pate, said in January that the ministry proposed N1.8 billion for the procurement of LLINs for additional three states, a World Health Organisation (WHO)’s report shows that Nigeria would need one billion dollars (N158 billion) to stave off backsliding and resurgences of malaria in 2013 and 2014.”

It would seem that the Senator was reacting to perceived pressure from the international community to maintain a malaria control strategy that he thought was less effective than indoor residual spraying (IRS).  Of course one of the biggest challenges in disease control advocacy efforts is to educate policy makers. The Director-General of the Nigerian Institute for Medical Research, Prof. Innocent Ujah, tried to do this. He pointed out cultural factors that inhibit net use – and in fact lack of serious community follow-up efforts after massive net distribution over the past 2-3 years, can be traced as one reason why LLINs may have been wasted.

The Senator did not realize that malaria control leading toward elimination needs a multifaceted strategy. IRS can be part, but has its own limitations of which one is expense.  In highly endemic, stable and year-round transmission environments like Nigeria, spraying would be needed twice a year.  We forget that Nigeria has already once tried IRS a few decades ago and abandoned the effort in part due to the huge logistical challenges required.

Nigeria has tried selling LLINs/ITNs through the private sector, but coverage was low since not all Nigerians could or would buy them despite paying disproportionately out-of-pocket for treatment. If the government refuses to fund massive LLIN distribution, then we can expect the burden to fall on the common people who may die from malaria before they purchase a more costly net on the commercial market.

For the love of a pesticide???

Some people love their spouse, some people love their new car, and apparently some people love DDT.

Love is not a particularly rational emotion, even more so when it comes to inanimate objects like cars and pesticides. Those who love DDT have now even equated stopping its use with population control in Africa.  One wonders where these same people stood when real ‘population control’ or genocide was happening in Rwanda and Darfur (to name a few of the more obvious human atrocities). Somehow one doubts banning of DDT can be equated with Darfur.

Long before DDT was banned, the malaria eradication efforts of the 1950s-60s were grinding to a halt in many African countries for the basic reasons that health systems could not support sustained efforts and donors were tiring of funding the project. There is also the not so simple matter of insects developing resistance when only one pesticide is being used.

who-ddt.jpgOne key lesson of the earlier eradication project was that relying on a single intervention technology was not enough to control, much less eradicate, a complicated disease like malaria.

Now that we have several proven tools (long lasting insecticide treated nets, artemisinin-based combination therapy, rapid diagnostic tests, intermittent preventive treatment AND indoor residual spray) in addition to new tools on the horizon (e.g. vaccines), we can apply those in combinations that best suit the epidemiological situation in each country and region of a country.

Yes, spraying was included above, and is an integral component of current malaria control and elimination efforts because it can now be targeted, as with the other interventions, in the most effective places such as areas that have more seasonal and unstable transmission and thus, where annual spraying can be effective. Yes, DDT is included in the WHO approved list of chemicals for indoor use, but for countries that want choice, there are a dozen alternatives.

Why annual spraying? DDT may be cheap, but the spraying operation is not. Nor is it convenient to the people whose homes are sprayed. Spraying more than once a year would be more time and cost consuming than present funding and community tolerance could support. Very high year-round malaria transmission settings are not so amenable to IRS as they would require more frequent spraying.  WHO recommends the following for appropriate IRS use in epidemiologically appropriate areas:

Achieving [the highest possible] level of coverage and timing spraying correctly – in a short period of time before the onset of the transmission season – are crucial to realize the full potential of IRS. IRS is indicated only in those settings where it can be implemented effectively, which calls for a high and sustained level of political commitment.

Approved use of any pesticide for public health comes with the following caution: “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides in agriculture, and thus contamination of agricultural products. Pesticide contamination can have serious ramifications for trade and commerce for countries exporting agricultural products.”

Those who love DDT may not find these concerns expressed about the object of their affection very comforting. But then love is fickle. Maybe next year these same people will fall in love with BPA.

Where is IRS most feasible?

In Nigeria’s Rivers State the State’s Malaria Control Coordinator reports on “efforts to roll back malaria in Rivers State, (in which) the state government says it would carry out indoor residual spraying (IRS) to terminate mosquitoes, the causative agent as from this quarter.”

The Coordinator has set up a timeline: “According to her, plans were already underway to purchase and distribute chemicals that would be used for the house-to-house spraying. She also said that if done every six months in the next three years, Rivers State would be free from malaria.”

WHO explains that, “The application of IRS consistently over time in large areas has altered the vector distribution and subsequently the epidemiological pattern of malaria in Botswana, Namibia, South Africa, Swaziland and Zimbabwe.” These are countries with large areas of unstable or epidemic malaria where annual spraying is effective.  Rivers State, Nigeria, as its Malaria Coordinator notes, requires twice a year spraying since it is an area of stable, intense and year-round transmission.

When the US President’s Malaria Inititive planned IRS in Ghana it chose districts in the Northern part of the country where malaria transmission is more seasonal and IRS can be cost-effective when used only once a year. For most of the country PMI is planning to distribute more than a million long lasting insecticide-treated nets as the appropriate strategy.

The Rivers State effort, while recognizing the need to adapt IRS timing to its ecological/epidemiological setting will still face huge challenges including –

  • dispersed, nearly inaccessible riverine communities
  • coordination among neighboring states where mosquito control efforts may not be as strong
  • ongoing civil disorder wherein “Militants in the Niger Delta attack pipelines and other oil facilities and kidnap foreign oil workers.”

Apparently the State is also relying on the bednet option, and “government had distributed four million insecticide treated bednets during the last immunisation campaign in the state. But this spraying option would ensure that even those who fail to clean their areas get the needed cover.” Nets can be distributed and monitored through a variety of community channels and last for 5 years if used properly.  This might be a safer and more viable vector control option for such a high transmission areas.

IRS in Uganda – a call for monitoring resistance

The National Academy of Sciences reports that, “The Ugandan government recently started spraying insecticides in homes and settlements to combat mosquitoes that spread malaria, the country’s leading cause of death.  A new report from a committee of the Uganda National Academy of Sciences (UNAS) says that as the spraying continues, the government needs to monitor mosquitoes for resistance to insecticides, and manage the spraying program in ways that minimize resistance.  UNAS is a participant in the African Science Academy Development Initiative, a joint effort of several African academies and the U.S. National Academies to advance science-based policy advice in Africa.”

The Committee that met to assess malaria vector resistance to insecticides used for indoor residual spraying in Uganda has looked at the strengths and weaknesses of the proposed “best practices” in IRS with an aim to maximize the effectiveness of DDT and other insecticides as well as identify contextual issues that would have a bearing on successful implementation of the “best practices.” In short the committee is not against IRS, but wants to ensure that it is carried out in the most safe and effective way.

The report of the Committee is available online. The report documents national policy and the fact that the Ministry of Health was authorized to begin IRS using DDT in August 2007 with support from the US President’s Malaria Initiative. Committee recommendations include establishment of sentinel surveillance sites, baseline entomological assessment, use a variety of factors ranging from susceptibility to cost and reliability of supply in selecting insecticides, and plan for long-term implementation, among others.

irs_worker.jpgPMI’s updated Uganda profile states that, “To date, more than 4,000 local personnel have been trained on proper spraying technique. Spraying has covered almost every targeted household in Uganda and benefited more than 1.8 million people.” In addition PMI’s Malaria Operational Plan for Uganda documents that PMI established insecticide resistance monitoring to IRS in Kabale with a training course in 2006 on the use of the bottle bioassay for mosquito insecticide resistance testing. Additional training and capacity building was planned for 2007. As a result of these activities, “The NMCP intends to monitor the level of susceptibility of malaria vectors to the insecticides scheduled for use in 2008, 2010, and 2012,” in selected sentinel sites as well as consider rotating insecticides to slow the development of resistance.

It would appear that the scientific, programmatic and donor communities are poised to deliver a safe and effective IRS intervention in Uganda. We would feel a bit more comfortable knowing whether Uganda is achieving some of the early milestones implied above – deployment and support of trained personnel, establishment of sentinel centers and conduct of baseline, for a start.

IRS vs Organic Farmers in Uganda

Nine companies engaged in organic farming in Lango sub-region’s districts of Oyam, Apac and Lira are suing the government of Uganda over the use of DDT for indoor residual spraying according to the Monitor. The Monitor reports the case as filed states that, “The decision by the government to introduce DDT in the districts is illegal as it contravenes the provisions of the Stockholm Convention on persistent organic pollutants of 2001.” WHO does clarify that the Convention says DDT can be used for public health purposes, but the question is, who defines the public’s health?

The farmers have logical fear that if DDT spraying inside houses is not done with proper precautions, their crops and livelihoods as organic farmers could be imperiled. Those pressing the suit claim that the agency contracted to do the work is in fact not following precautions and thus opening the potential to contaminate their crops. Let’s look at what is at stake.

In an overview of organic farming in Uganda, the International Trade Center explains that, “Uganda has the most developed sector of certified organic production in Africa. About 33,900 farmers manage 122,000 hectares of land using organic methods, an area that accounts for 1% of Uganda’s arable land (IFOAM & FiBL, 2006). Although still small and far below the increasing global demand, the country’s export of organic agricultural produce has been growing substantially in recent years. In Uganda, which has one of the lowest agro-chemical usages in Africa, the majority of farmers practice de facto organic agriculture without being certified yet (ACODE, 2006). Since no significant domestic market exists, certified organic agriculture targets mainly export markets in Europe and North America.”

In fact, the Monitor reported in 2007 that, “Organic farming has become a means of generating income for farmers and consequently fighting poverty.” Furthermore, “On the world market, Uganda’s export share of organic products has increased considerably and is the highest in Africa. The coordinator of Nogamu, Mr Moses Muwanga says 38 percent of organic agricultural production in Africa is from Uganda, with over 50,000 certified organic farmers. This makes Uganda one of the countries with the highest comparative advantage for organic production in Africa.” takes us to an organic farm in Tororo District and with pictures and text concludes that a Tororo farmer could, “teach farmers in Europe or America a thing or two. His type of farming — sustainable and organic — produces lots of food and lots of varieties of food. And it doesn’t need huge tractors, diesel fuel, artificial fertilisers and chemical poisons. As I said earlier, nothing is wasted.”


The Kulika Charitable Trust Uganda “has set up a sh800 million agricultural training institute at Lutisi, 37km on the Kampala-Hoima highway,” ( In short, there have been major investments in capacity building for organic farming in Uganda. “The core of Kulika’s Community Development Programme is training of farmers in sustainable organic agriculture which focuses on experiential learning, practical work, on-farm experimentation and demonstrations to improve the skills of farmers (see photo from Kulika).”

The economic issue here may be confusing – a chicken and egg debate. Does malaria control promote economic development or does economic development strengthen societies to control malaria. Assuming it is the latter scenario, we need to think twice about interventions that will affect the livelihoods of thousands of Ugandan farmers, specially when alternative control measures are available.

WHO recognizes that, “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides in agriculture, and thus contamination of agricultural products. Pesticide contamination can have serious ramifications for trade and commerce for countries exporting agricultural products.” The organic farmers in Uganda question whether adequate control is possible.

Pesticide safety – lessons from the green revolution

In light of the current world food crisis the BBC has re-examined the experiences of the Green Revolution. This high tech approach to increasing farm output appears on the surface to be a success in the Punjab of India. The BBC’s David Loyn reported on the experiences of one farmer: “Before Mr Singh’s father died young of cancer in 1992, none here suspected that the technology that had brought wealth to these farmlands in the 1970s might have a downside as well.”

Mr. Loyn looked more closely into the issue of the pesticides required by these crops. “The sprays all have instructions demanding that they should only be used with face masks and protective clothing. But the farm workers here do not use protective equipment, and they spray far more than the recommended amount. The cause of cancer is always a contentious issue, but a new study from the Punjabi University at Patiala ruled out other potential factors like age, alcohol intake and smoking, concluding that the way the sprays are used is causing cancer.”

Around a dozen insecticides are approved for use in Indoor Residual Spraying. WHO cautions that, “When implementing IRS, it is critical to ensure that adequate regulatory control is in place to prevent unauthorized and un-recommended use of public health pesticides.” Safety should be a major concern –

Another major consideration when selecting an insecticide is safety. Insecticides recommended by WHO are deemed safe for public health use under the recommended conditions of use. Concerns over the safety of DDT, a persistent organic pollutant, have also been comprehensively addressed in the framework of the Stockholm Convention on Persistent Organic Pollutants (POPs). The Convention bans the use of DDT, except for public health purposes. Therefore, DDT can be used for IRS where it is indicated, provided that stringent measures are taken to avoid its misuse and leakage outside public health.

lrg-102-img_1606_ethiopia_lowres-sm.jpgIn a comparison of the cost advantages of various insecticides that can be used for IRS, Walker (2000) emphasizes that safety measures must be included in the cost calculations. Even in the re-treatment of ITNs, WHO recommends that, “The use of rubber gloves is essential; mouth and nose masks should be worn when dipping large numbers of nets, especially with emulsifiable concentrate formulations.” The document also stresses that people who pack, mix and spray insecticides should also wear protective devices/clothing.

We hope that with proper care, supervision and protection of malaria workers, the community members they serve and the environment, we will see the history of today’s malaria control efforts written without the downside as experienced in the Green Revolution.

United Nations – ambitious plans for 2010

buttonwhite_fr.gifWorld Malaria Day is time for hope, and the United Nations Secretary-General, Ban Ki-moon, is not disappointing. The BBC reports that, “In a video message for a UN World Malaria Day event, the Secretary-General announces an initiative offering household sprays and bed nets treated with insecticide “to all people at risk, especially women and children in Africa” by the end of 2010.”

This is an almost unbelievable though desirable goal, much over the 80% RBM targets for 2010. The Secretary-General prefers to call this goal “bold, but achievable.” Even with help from GFATM, PMI, the World Bank Booster program, UNITAID and others, many countries are struggling to meet the 2005 target of 60% coverage of vulnerable populations with ITNs and medicines. The new UN malaria envoy, Ray Chambers has done the math –

  • 500 million additional people
  • 250 million additional ITNs/LLINs
  • less than 1,000 days to achieve this
  • “That’s four-to-five times what we’ve done in the past”

While this effort will push us toward eradication, Chambers is realistic in stating that the goal of complete elimination of the disease will depend on vaccine development, which is still some years away.

Reuters News also adds a note of realism by quoting a statement from the U.S. National Institutes of Health which said that malaria has proven to be “remarkably resilient, resurging because of the emergence of drug-resistant parasites and insecticide-resistant mosquitoes.” Reuters also mentions the unknowns created by global warming for consideration. These concerns add a sense of urgency that simple mentioning of 2010 may not confer.

Ironically, targeting these new malaria intervention and coverage goals comes on the heels of concern that African countries, where malaria is endemic, are unlikely to meet the Millennium Development Goals, which include malaria reduction. Clearly there are serious challenges in terms of finance and health systems issues to achieving universal overage in under 1,000 days – we hope all partners will heed this challenge on World Malaria Day and work together to meet it.