A consensus has evolved that as malaria interventions become more widespread and successful, the need for Artemisinin-based Combination Therapy (ACT) medicines will decrease in endemic countries.Â As a case in point, The RBM Needs Assessment produced by Burkina Faso in 2008 and used as a base for planning the Round 8 GFATM proposal projected a decline in the number of P. falciparum malaria cases and hence, a decrease in the need for ACT supplies.
While the attached chart shows a projected decrease in malaria cases starting in 2009, there is little evidence that LLIN distribution and use are adequate enough at present to produce such a drop.Â Burkina Faso’s RBM Road Map shows that the most recent coverage is LLINs is 24% for children below 5 years of age and 28% for pregnant women.
Furthermore, the major distribution campaign to achieve universal coverage of LLINs in Burkina Faso is not slated to take off until July 2010 at the earliest.
Specifically, the Global Fund reports that, “The Global Fund has shown that where distribution of insecticide-treated bed nets (ITNs), spraying and treatment are scaled up to national population coverage, malaria cases and child mortality can be reduced by up to 50 percent.” It appears that in the countries cited, less than 80% coverage was able to achieve up to 50% reduction in cases over a couple years.
The major challenge though is how to ensure coverage/use after a big campaign, since actual use if often much less than proportions of households possessing nets. Then too, there is the challenge of promoting continued use. Lea Pare Toe and colleagues recently reported research findings on decreased motivation to use ITNs in Burkina Faso. Factors included –
- Acceptance was moderated by the fact that mosquitoes not seen as only cause of malaria
- Use of ITNs adversely affected by functional organization of the houses: e.g. if also cook in sleeping areas, see nets as fire hazard
- Bednets not used when perceived benefits of reduction in mosquito nuisance and of malaria were considered not to be worth the inconvenience of daily use
Universal coverage is not a one-time event. It must be maintained for many years. There must be continuous supplies of nets for new people and to replace old nets.Â If after 3-4 years coverage falls, severe cases and mortality will rise as populations would have lost immunity.
And finally, any reduction in ACT need and use depends on use and acceptance of RDTs.Â As the chart above shows, we will have no shortage of fever illness episodes even as malaria reduces.Â Unless we couple diagnosis AND treatment, ACTs will be wasted and shortages will arise, especially if we reduce our orders of ACTs before we are sure that universal net coverage effects have really begun.