Tropical Health Matters

WHO says, “Malaria elimination and universal health coverage go hand in hand,” at a special event during the 72st World Health Assembly. To achieve zero malaria, the goal of involving everyone from the policy maker to the community member must have a focus on achieving universal health coverage (UHC) of all malaria interventions ranging from insecticide treated bednets (ITNs) to appropriate provision of malaria diagnostics and medicines. Many of the studies to date have focused on ITNs, which include long-lasting insecticide treated nets (LLINs), but nationwide monitoring through the Demographic and Health Surveys (DHS), the Malaria Indicator Surveys (MIS) and the Multi-Indicator Cluster Surveys (MICS).

UNICEF’s website provides a data repository that includes the most recent DHS, MIS and MICS survey data per country between 2014 and 2017. For the indicator of one ITN per to people in a household, shows Angola at only 13%, most countries for which recent data are available reached between 40-50%. Only two achieved above 60% on a point-in-time survey, Uganda at 62% and Sao Tome and Principe at 95%. The website shows information that where there were multiple surveys in a country during the period, there were variations, sometimes quite wide, over the years. Aside from the fact that the surveys may have had slightly different procedures, the problem remains of achieving and sustaining UHC for ITNs.

Another factor that affects maintaining UHC for ITNs, assuming the target can be met is the durability of nets. The physical integrity as well as the insecticide efficacy can decline over time. Intact nets may lose their insecticide through improper washing and drying, yet still prevent mosquito bites to the individual sleeping under them. Nets with holes may still maintain a minimal level of effective insecticide and may not fully prevent bites but ultimately kill the mosquito that flies through. Researchers in Senegal have been grappling with these challenges.

Program managers must themselves grapple with whether such compromised nets count toward universal coverage as well as how often to conduct net replacement campaigns. A report from community surveys in Uganda during 2017 found that, “Long-lasting insecticidal net ownership and coverage have reduced markedly in Uganda since the last net distribution campaign in 2013/14.” UHC for ITNs is always a moving target.

A frequently unaddressed issue in seeking to improve ITN coverage is whether it makes a difference in malaria disease. A study in Malawi reported that although ITNs per household increased from 1.1 in 2012 to 1.4 in 2014, the prevalence of malaria in children increased over the period from 28% to 32%. The authors surmised that factors such as insecticide resistance, irregular ITN use and inadequate coordinated use of other malaria control interventions may have influenced the results. This shows that UHC for ITNs cannot be viewed in isolation.

This brings up the issue of the role of the many different vector control measures available. Researchers in Côte d’ Ivoire examined the use of eave nets and window screening. At present eave nets are mainly deployed in research contexts but use of window and door screening and netting are a commercially available interventions that households employ on their own. One wonders then whether UHC should focus on how the household and the people therein are protected by any malaria vector intervention.

Here the discussion should focus on the question raised by colleagues in the USAID/PMI Vectorworks Project. WHO declared a goal of universal ITN coverage in 2009 using the target f one ITN/LLIN for every two household members. Vectorworks found that a decade on only one instance of a country briefly achieving 80% of this UHC net target, whereas no others reached above 60%. In fact, the bigger the household, the less chance there was of meeting the two people for one ITN target. Just because people live in a household that has the requisite number of nets, does not guarantee the actual target for sleeping under a net can be achieved because of practical or cultural realities in a household. Neither the minimal indicator of having at least one net in a household, or the ideal or ‘perfect’ indicator of UHC are satisfactory for judging population protection.

The Vectorworks team suggests that, “Population ITN access indicator is a far better indicator of ‘universal coverage’ because it is based on individual people,” and can be compared to, “The proportion of the population that used an ITN the previous night, which enables detailed analysis of specific behavioral gaps nationally as well as among population subgroups.” Population access to ITNs therefore, provides a batter basis for more realistic policies and strategies.

We have seen that defining as well as achieving universal coverage of malaria interventions is a challenging prospect. For example, do we base our monitoring on households or populations? Do we have the funds and technical capacity to implement and sustain the level of coverage required to have an impact on malaria transmission and move toward elimination? Are we able to introduce new, complimentary and appropriate interventions as a country moves closer to elimination?

A useful perspective would be determination if households and individuals even benefit from any part of the malaria package, even if everyone does not have access and utilize all components. This may be why zero malaria has to start with each person living in endemic areas.

World Health Day 2018 is promoting universal health coverage. National Health Insurance Schemes (NHIS) are seen as a way to foster universal health coverage by improving access to basic, life-saving care. In malaria-endemic countries, NHIS hopefully play a role in reducing malaria mortality. For example in Nepal, malaria was among the chronic and communicable illnesses that showed increased catastrophic health expenditure over time leading to impoverishment. Health insurance was seen as a way to counteract this problem.

Although health insurance coverage in Tanzania was quite low, “a higher proportion of women with health insurance had a proper timing of 1st ANC attendance compared to their counterparts.” This enables them to access malaria prevention services and interventions.

Ghana has been operating a NHIS since 2003. Overall national coverage has been estimated at around 40%, with a greater proportion of women covered than men. The 2014 Demographic and Health and 2016 Malaria Indicator Surveys (DHS, MIS) show that around 60% of women of reproductive age have NHIS coverage. How does this translate into malaria service coverage?

In Ghana a decrease in malaria deaths was seen against a backdrop of increased admissions owing to free access to hospitalization through the NHIS, but hospital admission is not an option for all. Community case management is aimed at increasing access to and coverage of timely management of malaria and other child illnesses, but such services may not be covered by a NHIS. Since iCCM is effective in reaching children, Ghana is questioning how community based health workers can be brought into the health insurance arena.

Rwanda started its community based health insurance scheme in 2003 also and by 2013 had achieved 74% coverage. In Rwanda community malaria action teams (CMATs) were initiated in mid-2014 as platforms to deliver malaria preventive messages at village level. Among other benefits of the CMATs, an increase in community-based health insurance membership occurred,

Mutuelle (community health insurance) kiosk outside a clinic in Burkina Faso

which was also considered as a predictor of prompt and adequate care. Another study in Rwanda showed that head of household having health insurance (among other factors) was significantly associated with prompt and adequate care for presumed malaria illness.

NHIS have their own challenges in terms of affordability, community understanding of payment of premiums and availability of points of care that accept insurance or are accredited. And not all endemic countries have achieved even the modest successes of NHIS in Ghana and Rwanda. Thus health insurance offers hope for expanding universal coverage of malaria services, but health systems and community understanding and participation need to be improved for this to happen.

Universal Health Coverage (UHC) is the theme of the 2018 World Health Day on April 7th. The concept was applied to malaria in 2009 regarding the provision of long lasting insecticide-treated nets (LLINs aka ITNs) with the definition of universal meaning one net for every two persons in a household. Up until that time coverage targets for malaria interventions set at the 2000 Abuja Declaration had focused on achieving by the year 2010, 80% of people (particularly pregnant women and children below the age of 5 years) sleeping under ITNs, 80% of children receiving appropriate malaria treatment with artemisinin-based combination therapy (ACTs) within 24 hours of onset of illness and 80% of pregnant women receiving two doses of Intermittent Preventive Treatment (IPTp) for malaria as part of antenatal care (ANC).

Definitions have evolved since the Abuja Declaration. The target for ITNs was extended to all household members (thus universal). The ACT target was modified to require treatment based on parasitological testing (microscopy or rapid diagnostic tests). IPTp targets were extended to achieving monthly dosing from the 13^th week of pregnancy, which depending on the point in pregnancy when a women entered the ANC system could be 3, 4 or more doses. In addition to these changes, the US President’s malaria Initiative upped the Abuja targets from 80% to 85% in the countries where it supported national malaria programs.

We are eight years past 2010. It had been assumed that if scale up to 80% had been achieved by then and sustained for five or more years, malaria deaths would come close to zero and elimination of the disease would be in sight. National surveys have shown that reaching these targets has not been simple.

The example of ITNs is a good place to start, as is Nigeria with the highest burden of malaria. The attached chart shows findings from the Demographic and Health or Malaria Information Surveys in 2010, 2013 and 2015. Whether one measures universal coverage by the house possessing at least one net per two residents or by the proportion who actually use/sleep under the nets, we can see that UHC for this intervention is difficult to achieve. Even when households possess nets, not everyone sleeps under them either because of adequacy of nets, preferred sleeping arrangements, internal household power structure or other factors.

In 2015 the majority of nets that existed in households were obtained through campaigns (77%), 14% were acquired from the health services, and 7% were purchased. These systems are not keeping up with the need.

Four endemic countries reported a malaria Information Survey in 2016, Liberia, Ghana, Madagascar, and Sierra Leone. The chart shows that they too have had difficulty in achieving universal coverage of malaria interventions. Of note the chart only includes whether appropriate malaria parasitological diagnosis was done on children who had fever in the preceding two weeks. Data on provision of ACTs is based on fever, not test results, so there is no way to know whether it was appropriate. Generally 20-30% more febrile children received ACTs than were tested.

All three malaria interventions, ACTs, Diagnostics and ITNs, require contact with the health system (including community health workers). If malaria services are indicative of other health interventions, then universal coverage including seeking interventions, getting them and ultimately using them is still a distant goal. To achieve universal coverage there also needs to be universal commitment by countries, donors and technical partners.

The first time the global community observed a day devoted to tackling the problem of malaria was April 25^th 2001. This was agreed upon at the African Summit on Roll Back Malaria held in Abuja, Nigeria in 2000. The first seven annual observances were titled “Africa Malaria Day,” and recognized that the largest global burden of the disease affects people on the African continent. As thoughts moved toward elimination, the importance of addressing all endemic communities resulted in the first “World Malaria Day” in 2008.

Thus on April 25^th 2017 we are observing the 17^th Malaria Day overall and the 10^th anniversary of World Malaria Day. This observance has been complimented over the years with a malaria day for the Southern African Development Community and for countries in the Americas.

Each year Malaria Day has had a theme or themes to help focus education and advocacy. Regardless of the theme, the special day has been a time to mark progress and rally partners from the global to community level to continue the fight against the disease. The list below shows some of the issues/themes raised on the past Malaria Days. As noted, in some years advocacy efforts dealt with more than one key idea, though all are not presented.

• 2001 – Africa Malaria Day 2001: The First Africa Malaria Day; Malaria – A Crisis With Solutions; A Malaria Free-World
• 2002 – Mobilizing Communities to Roll Back Malaria
• 2003 – Insecticide Treated Nets and effective malaria treatment for pregnant
• women and young children
• 2004 – A Malaria-Free Future: Children for Children to Roll Back Malaria
• 2005 – Unite against malaria: Together we can beat malaria
• 2006 – Get Your ACT Together: Universal Access to Effective Malaria Treatment is a Human Right
• 2007 – Leadership and Partnership for Results
• 2008 – Malaria, A Disease without Borders
• 2009 – Counting Malaria Out
• 2010 – Counting Malaria Out; (and in the Africa Region) Communities engage to conquer malaria!
• 2011 – Achieving Progress and Impact
• 2012 – Sustain Gains. Save Lives. Invest in Malaria
• 2013-15 – Invest in the Future: Defeat Malaria
• 2016-17 – End Malaria for Good

In sum these themes emphasize the importance of access to malaria interventions, documenting that access, using the data to stimulate more investment ultimately leading to an end (elimination) of malaria. The most recent World Malaria Report (2016) provides several important examples of the progress so far.

• Households with least one ITN increased to 79% in 2015
• 53% of the population at risk slept under an ITN in 2015 in Africa increasing from 30% in 2010
• The proportion of suspected malaria cases receiving a parasitological test in the public sector increased from 40% in the WHO African Region in 2010 to 76% in 2015
• In 2015, 31% of eligible pregnant women received three or more doses of intermittent preventive treatment in pregnancy (IPTp) among 20 countries with sufficient data, a major increase from 6% in 2010

In addition to noting progress, the report also points out gaps in appropriate care seeking for malaria, attendance at antenatal care clinics, and adequate numbers of nets for a household. As implied in the IPTp data, there is the additional problem of obtaining timely and accurate date to document progress and/or gaps. Looking at the Malaria Day themes around investing, we know that unless one can show investors results, it will be difficult to “End Malaria for Good.”

Rwanda is experiencing low and very low levels of malaria test positivity rates, thought there are a few districts near the borders with Uganda, Tanzania and Burundi that have relatively higher transmission. Overall the country is strategizing how to move toward the pre-elimination phase on the pathway to malaria elimination. This is defined as a test positivity rate of less than 5% during the high transmission season.

It is important to distinguish between test positivity rate and prevalence rate. The most recent survey report that gives prevalence is the DHS 2010 with a rate of 1.4% in children below 5 years of age and 0.7% among women of reproductive age. During 2010 the health management information system shows that among those tested (microscopy or RDT) for malaria, 24% were positive. The population for test positivity reports is a much smaller group that is already suspected of having malaria. That said, 24% or the 2013 rate of 29% is still far from the 5% cut-off for pre-elimination status.

Rwanda still maintains a policy of universal coverage with insecticide treated nets (ITNs). Rwanda also has a policy that every pregnant woman should receive an ITN during her first antenatal care visit. Ideally in order to reach pre-elimination status, a country needs to sustain high coverage of malaria prevention and treatment interventions at an 80% level for several years.

The newly released preliminary results of the 2014-15 DHS provide an opportunity to examine achievements. The 2014-15 DHS found that 81% of households had at least one ITN, while 43% had achieved the universal coverage target of one ITN per two household members. These numbers remain basically unchanged from the 2013 Malaria Information Survey (83% and 43%), while the 2010 DHS found 82% of households had a net, but did not report on the indicator of one net per two people. In short, it appears that coverage levels have been maintained at a certain level.

DHS 2014-15 shows that 99% of pregnant women in Rwanda received antenatal care from a skilled provider. That means that basically all pregnant women should have received an ITN. 73% of pregnant women had slept under an ITN the night before they were surveyed, while 88% of all women of reproductive age slept under a net. 68% of children below the age of five years slept under an ITN the night before their household was surveyed, while 80% who lived in households that owned an ITN did so.

Indoor Residual Spraying (IRS) is focused on certain high transmission/burden districts. The preliminary 2014-15 DHS does not report on this and the 2013 MIS reports broadly by region, hence one sees coverage reports for IRS in the east (22%) and south (16%), where there is greater malaria burden, but this cannot be linked to specific districts that may have been targeted.

Rwanda also has a policy that all suspected malaria cases should be tested, whether with microscopy in health centers or rapid diagnostic tests by village health workers. It is only those persons testing positive for malaria who are supposed to be given malaria medicine.

DHS shows that 1439 children below five years of age (or 19% of the total) had fever in the two weeks prior to the survey. Of these 36% reported having a blood test performed, and 11% of those with fever received the approved artemisinin-based combination (ACT) therapy drug. The report does not indicate the actual test results of those receiving ACT.

As Rwanda strategized toward reaching malaria pre-elimination status it can consider ways of enhancing ITN use, not only among vulnerable groups like small children and pregnant women, but all members of the household. As prevalence drops, so does acquired immunity, putting adults at greater risk.

The universal coverage target of at least 1 net for every two people in a household must be maintained, especially since it is nearing three years since the last universal coverage distribution campaign. Either another campaign will be needed or efforts to strengthen delivery of nets to families through routine health services.

In addition prompt and appropriate treatment based on diagnostics can be strengthened. One would have expected more children with fever to have been tested for malaria that the DHS reports.

Internal and external support is needed. Rwanda has been on the verge of reaching malaria pre-elimination status several times in the past decade. Even though malaria is no longer the top cause of death, we should not reduce our efforts to create a malaria-free Rwanda.

In New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

1. A strong, efficient, well-run health system
2. Affordable care
3. Accessible care
4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

While much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.

World Malaria Day 2014 was observed at the Johns Hopkins Bloomberg School of Public Health. Admiral Tim Ziemer, the Coordinator of the US President’s Malaria Initiative was keynote speaker. Other speakers from the NGO and faith based organization community also talked about the importance of partnership in fighting a disease that still claims 600,000 lives annually.  In addition 21 posters were presented.

Below is the abstract of one poster representing our work with USAID’s Targeted States High Impact Project in Nigeria.

Malaria and febrile illness care seeking in Bauchi State, Nigeria: context for improving case management at the primary level

Seeking of appropriate and quality care for childhood illnesses is a major challenge in much of Africa including Bauchi State, Nigeria. In advance of an intervention to improve available care in the most common points of service (POS), government primary health care centers (PHCs) and patent medicine vendors (PMV), a survey was done of child caregivers in four districts concerning responses to febrile illness, suspected malaria, acute respiratory disease and diarrhea. The ethical review committee in the Bauchi State Ministry of Health approved of the study.

A total of 3077 children below the age of five were identified in the households sampled. Their mothers, fathers or other caregivers consented and were interviewed. Among the children 74% had any Illness, 57% had fever, 26% had cough, and 15% had diarrhoea. Only 8.7% of 1186 febrile children had their blood tested.

Care seeking from PMVs varied from 45% with fever, 40% with cough to 36% with diarrhoea. Care from public sector POS varied from 26-33%. Treatment that might be considered ‘appropriate’ for each also varied with 30% receiving antimalarial drugs for suspected malaria, 20% getting oral rehydration solution for diarrhoea and 50% being given an antibiotic for a suspected acute respiratory illness.

The results show that providing quality integrated case management with appropriate commodities through PHCs and PMVs can improve the illness care of a majority of children in Bauchi State, and interventions are currently being planned to do this.

Poster by … William R. Brieger, MPH, CHES, DrPH ¹, Bright Orji, MPH ², Masduk Abdulkarim ³, (1) International Health, Bloomberg School of Public Health, The John Hopkins University, 615 N Wolfe St, Baltimore, MD 21205 (and Jhpiego). (2) Jhpiego, Thames St, Baltimore, MD 21231`. (3) Targeted States High Impact Project USAID Nigeria, Bauchi, Nigeria.

The World Health Report 2013 entitled Research for Universal Health Coverage has been released. Since universal coverage has been a central Roll Back Malaria target since 2009, we have included below some of the mentions of studies and activities around malaria service provision and scaling-up.

The case for investing in research is made, in part, by demonstrating that scientific investigations really do produce results that can be translated into accessible and affordable health services that provide benefits for health… In one (example) a systematic review of survey data from 22 African countries showed how the use of insecticide-treated mosquito nets was associated with fewer malaria infections and lower mortality in young children. This evidence underlines the value of scaling up and maintaining coverage of insecticide-treated nets in malaria-endemic areas. (page xiv)

(Environmental risk factors) also contribute to the transmission of vector-borne diseases: malaria is associated with policies and practices on land use, deforestation, water resource management, settlement siting and house design. (Page 41).

By killing or repelling mosquitoes, insecticide-treated bed nets protect the individuals sleeping under them from malaria. By killing mosquitoes, they should also reduce malaria transmission in the community. Randomized controlled trials conducted in sub-Saharan Africa in a range of malaria endemic settings have provided robust evidence of the efficacy of ITNs in reducing malaria parasite prevalence and incidence and all-cause child mortality. Such trials showed that ITNs can reduce Plasmodium falciparum prevalence among children younger than five years of age by 13% and malaria deaths by 18%. (page 61)

(More research is needed because) In contrast with the findings of controlled trials, ITNs may be less effective in routine use because the insecticidal effect wears off, or nets may be used inappropriately or become damaged. The impact of ITNs, as used routinely, on malaria and childhood mortality is therefore uncertain.  (page 62)

As we can see from the World Health Report, malaria research has made a major contribution to our understanding of factors and effects of scaling up programs to try to achieve universal coverage.  As WHO recommends, more funding for health service coverage is needed, and malaria countries countries themselves need to contribute their own share in supporting their own research institutions.

While today it technically the sixth World Malaria Day, one should actually trace the origins back 13 years to the first Africa Malaria Day (AMD) in 2001, held to encourage progress based on the Africa malaria Summit in Abuja just one year before.  And since the Abuja summit and its resulting declaration were backed by the Roll Back Malaria Partnership, which formed in 1998, one could say the world has 15 years to considering in judging progress in and plans for partner investments in ridding the world of malaria.

In 2001 organizers of Malaria Day events were encouraged to feature a ‘new’ medicine that WHO said could save 100,000 child healths annually in Africa. artimisinin-based combination therapy (ACT) drugs are now the front line treatment in most all endemic countries, and deaths have declined somewhat on the order of 400,000. At that time there was only one major manufacturer of ACTs. Investments by pharmaceutical companies in generic ACTs now means that there are at least nine companies that produce prequalified ACTs. What is needed is more indigenous African pharmaceutical companies approved to invest in ACT production.

The first AMD stressed the risk of malaria to pregnant women and recommended widespread use of Intermittent Preventive Treatment in pregnancy (IPTp).  This recommendation has been adopted in countries with stable falciparum malaria transmission, but has lagged in terms of implementation, and coverage still lags below the 80% target set at the 2000 Abuja Summit.  There are missed opportunities to provide IPTp at antenatal clinics due to stock-outs, provider attitudes, and client beliefs. Weak health information systems mean that even when services are provided, reporting may not accurately reflect true coverage of IPTp.

In the meantime resistance is growing to sulphadoxine-pyrimethamine (SP), the drug used for IPTp in part due to the inability or unwillingness of country drug authorities to curb its inappropriate use for case management.  WHO now recommends more that the original two IPTp doses and suggests that pregnant women get SP at each ANC visit after quickening.  In the meantime research is underway to find substitutes for SP.

The first AMD addressed the role of insecticide treated nets (ITNs) in helping halve the world’s malaria burden by 2010.  Major progress came in 2008 when the whole United Nations community and of course companies invested in net production got behind universal coverage. In addition the advent of the long lasting insecticide-treated net with insecticide infused in the fabric from point of production pointed the way to success.

These three core interventions – ACTs, IPTp and ITNs – have been strengthened with better diagnostics and a variety of other vector control measures, Hopes for a vaccine still remain a dream, though an achievable one.  While we have high expectations for eradication, we can see that some of the health systems challenges that thwarted the first malaria eradication effort are still with us including weak procurement and supply management, inadequate human resources and gaps in health information systems.

The foregoing implies that we need at least two forms of future investment in malaria. First is investment by governments in strengthening the health system that deliver malaria services. The second investment is in continued biomedical research in order to fend off resistance by mosquitoes and parasites and of course social research to address issues of behavior, adoption of innovations and program management practices. Let’s hope that when World Malaria Day 2014 rolls around, we can measure these increases investments.

Youth, those 15-24 years old, are usually thought to be generally healthy and often do not occupy the minds of health planners. It is the pre-school age child who dies from infectious diseases and the older adult who succumbs to non-communicable afflictions. Actually as an e-mail today from USAID points out …

Approximately 16 million girls between the ages of 15 and 19 give birth each year. The impact of pregnancy on adolescent girls can be devastating: girls who become pregnant face a higher risk of maternal mortality, often drop out of school, and are sometimes forced into early marriage. In 2009, nearly 2.5 million boys and girls under the age of 15 were living with HIV, and 370,000 were born HIV-positive. For many, HIV has become a chronic disease that requires lifelong treatment, care, and support.

Pregnant teens living in malaria endemic areas are usually at high risk because it is the first and second pregnancies especially that are more prone to the disease and the anemia, miscarriage, still birth and possible death that comes in its wake. For example, researchers in Western Region, Ghana recently found that …

… adolescent pregnant girls were more likely to have malaria and anaemia compared to their adult pregnant counterpart. Results from this study shows that proactive adolescent friendly policies and control programmes for malaria and anaemia are needed in this region in order to protect this vulnerable group of pregnant women.

Of course, youth are not only victims of malaria, but agents for change. A youth group in Uganda has launched the  Make Malaria History Campaign (MHC) and plans to distribute over 100,000 treated mosquito nets. Youth often organize community drama to highlight health issues as seen in the photo from Bauchi State, Nigeria.

Elimination of malaria means protecting all segments of the population in the spirit of universal coverage. Youth are not an exception.