World malaria report 2021

What impact did the COVID-19 pandemic have on the ability of malaria-endemic countries to provide malaria preventive services and treatments? And what impact did this have on cases and deaths?

At the beginning of the pandemic, there were major concerns that malaria services would be severely disrupted and that, under a worst-case scenario, 20 years of gains against the disease would be lost. The world rallied, WHO and global partners provided timely guidance and support, and countries made impressive adaptations in their malaria programmes to ensure the safe delivery of services. The latest data show that the worst-case scenario was averted.

However, despite the impressive efforts of malaria-endemic countries, this year’s report shows that disruptions, although moderate, still led to notable increases in malaria cases and deaths. Globally, there were an estimated 14 million more cases and 47 000 more deaths linked to disruptions during the pandemic. Most of these increases were reported in the WHO African Region.

The level of impact on malaria prevention, diagnosis and treatment services varied across countries. Seasonal malaria chemoprevention programmes suffered minimal disruptions during the pandemic. Thirteen countries in the Sahel subregion of Africa reached 11.8 million more children in 2020 compared with 2019.

About three quarters (72%) of the insecticide treated nets (ITNs) that had been planned for distribution reached target communities by the end of 2020. Many countries in sub-Saharan Africa also experienced disruptions to malaria diagnostic testing early in the pandemic. Health facilities in 15 countries saw reductions of more than 20% in testing between April–June 2019, compared to the same period in 2020.

Although difficult to quantify, available information suggests that there have also been moderate disruptions to malaria clinical services. For example, national malaria programmes reported distributing about 48 million fewer courses of artemisinin-based combination therapies (ACTs) in 2020 than in 2019.

In addition to the pandemic, many malaria-endemic countries have been dealing with other humanitarian and health emergencies including conflicts, flooding and other disease outbreaks, all of which affected malaria services.

What special measures did countries and their partners take to prevent a worst-case scenario of cases and deaths from malaria during the pandemic? 

A modelling exercise by WHO and its partners published in April 2020 advocated for the need to act swiftly to avert a disaster. WHO, together with global malaria partners, were quick to develop and share guidelines to help countries adapt and safely maintain essential health services during the pandemic. Donors for their part either mobilized additional resources or created flexibilities within existing grants to these adaptations.

Most importantly, country programmes responded quickly and courageously to ensure services reached communities. They adapted WHO global guidance to include the use of personal protective equipment in the deployment of malaria interventions. Many countries also successfully engaged communities in the delivery of such services. In the absence of such responses, they could have endured a severe reversal of progress against malaria. It’s important to note, however, that the danger is not fully behind us.

The pandemic is far from over and less than 5% of populations in most malaria-endemic countries are vaccinated against COVID-19. Countries must continue to simultaneously mitigate the immediate health impacts of COVID-19, reduce disruption to other essential health services, including malaria, and manage the health of their populations as broader economic disruptions affect their societies. Increased attention and financial support are needed to both control malaria and strengthen primary health care delivery.

The pandemic further slowed progress against malaria in many countries, and in some cases progress was reversed. What countries and regions were hardest hit, and why?

In most of the moderate and high burden countries in sub-Saharan Africa, both cases and deaths increased in 2020 compared to the previous year. Generally, the higher the baseline burden, the higher the estimate of additional cases and deaths.

Ten of the world’s 11 highest burden countries are in Africa, and they all reported an increase in cases and deaths in 2020. India, the 11^th country, registered declines in cases and deaths, but the rate of decline slowed in 2020 compared to pre-pandemic years.

Increases were not limited to African countries. A number of countries in other regions, especially in the Americas and the Eastern Mediterranean regions, experienced an increase in cases and deaths in 2020. In the Region of the Americas, for example, Haiti and Nicaragua registered increases of more than 20 000 cases and 16 000 cases, respectively, between 2019 and 2020.

What countries and regions had the most success, and why?

In the middle of a pandemic, it is difficult to quantify what success means. Is it a situation where a country with a high burden of malaria and weak health system has registered moderate increases in cases and deaths but has impressively averted a disastrous scenario? Or is it when a middle-income and low-burden country with a relatively strong health system has registered continued reductions in the burden of malaria?

Despite reversals, many moderate- and high-burden countries mounted successful efforts to mitigate the worst-case scenario during the pandemic. There are also a number of countries with a low burden of the disease that, despite the pandemic, registered continued reductions in the burden of malaria. Many of these are countries with reasonably strong health systems and relatively strong economies.

At the regional level, only South-East Asia reached the 2020 milestones of the WHO global strategy calling for reductions in case incidence and mortality rate of 40% or more, compared to a 2015 baseline. While other regions did not meet these milestones, region-wide trends mask, in some cases, country-level successes.

For example, although the WHO Eastern Mediterranean Region missed the 2020 case incidence milestone, the Islamic Republic of Iran and Pakistan bucked this trend. In 2020, Iran reported zero malaria cases for the third consecutive year and Pakistan reduced its malaria case incidence by more than 40%.

Why has progress against malaria levelled off in recent years – even prior to the pandemic?

The reasons for this vary by country. In some cases, the plateau in progress can be linked to reduced coverage of malaria control interventions or delays or inefficiencies in their scale-up. Other factors include poor or worsening performance of health systems or climate-related anomalies, such as excess rains and flooding.

From a financing perspective, the level of external and domestic funding for malaria has remained relatively unchanged for several years, despite a rapidly growing population and increasingly expensive interventions. This has limited the resources available to cope with malaria in at-risk countries with high population growth.

WHO is working with countries and partners in several high burden countries to try to understand and map the major drivers of the stalled progress and how best to respond to them.

How far off track is the world from meeting global targets to end malaria?

The WHO Global technical strategy for malaria 2016-2030 (GTS) aims to reduce malaria case incidence and mortality rates by at least 40% by 2020, at least 75% by 2025, and at least 90% by 2030 (against a 2015 baseline). Despite the considerable progress seen since 2000, the 2020 case incidence and mortality milestones have not been achieved globally.

Based on current estimates, the global malaria case incidence rate was 59 cases per 1000 people at risk, against a target of 35 – putting it off track by 40%. The global mortality rate was 15.3 deaths per 100 000 people at risk, against a target of 8.9 – putting it off track by 42%. Most of the countries that are off track are in the WHO African Region and the Region of the Americas.

How important is the newly approved RTS,S/AS01 vaccine? 

In October 2021, WHO recommended the first-ever malaria vaccine for children living in Africa and in other areas with P. falciparum transmission. The recommendation was based on the full package of evidence on RTS,S – including from a pilot programme in 3 African countries (Ghana, Kenya, Malawi) that has reached more than 830 000 children with the vaccine since 2019.

RTS,S has already had substantial public health impact when delivered through routine systems in the 3 countries. This includes a significant reduction in deadly severe malaria in the pilot areas, even though insecticide-treated nets are widely used and there is reasonable access to diagnosis and treatment. Modelling studies have shown that the vaccine is highly cost effective in areas of moderate to high malaria transmission.

As a proven technology, RTS,S is well positioned to lower malaria-related illness and death in Africa and in other areas with moderate and high transmission and disease.

Demand for the vaccine is expected to be high, and supply in the near to medium term will be limited. Working closely with Gavi, WHO looks forward to supporting expanded capacity and supply of the RTS,S vaccine to reduce any supply gap.

How much funding is needed to tackle the problem of malaria? During this time of global economic crisis, an ongoing pandemic, and rising debt loads of lower-income countries, where will the funding come from?

The WHO global malaria strategy includes a funding target of US$ 6.8 billion for the year 2020. According to the latest report, only about half that amount (US$ 3.3 billion) was invested in the global malaria fight last year. 

More resources must be mobilized for malaria at both domestic and international levels, while at the same time demonstrating that national and global efforts are maximizing the use of current investments.

Why did WHO revise its statistical method for estimating malaria deaths in children? What makes the new method more accurate and how confident are you in the results?

WHO works across UN agencies and academic partners to quantify the number of people who die each year and the causes of their deaths. Assessing the number of deaths among young children in low-resource settings, where data may be sparse, can be a challenge. But these cause-of-death estimates are very important – particularly for malaria, as a majority of deaths occur in this age group.

Until now, WHO had used a standard regression statistical approach to quantify the causes of death of children under the age of 5. This year, WHO has moved to a more robust method based on Bayesian statistics that can handle sparse data better, produce more reliable results, and do a better job of quantifying uncertainties. The change in method has had an effect on the malaria mortality estimates in 32 countries in sub-Saharan Africa that account for 93% of the global burden of malaria deaths.

In the case of malaria, the net effect of this change is that the mid-point annual estimate of the number of malaria deaths in children under the age of five is significantly higher than previously recognized for the entire period 2000–2020. This suggests that the actual toll of malaria on young children may have been underestimated, mainly in Africa, using the previous method.

It is important to note that the increased number of malaria deaths in 2020 therefore has two distinct and unrelated origins: the use of a new methodology (an additional 22 000 deaths) and disruptions in malaria services during the pandemic (an additional 47 000 deaths). The new methodology affects the estimates across the entire annual time series since 2000, while the disruptions during the pandemic apply only to 2020. 

We have yet to see how COVID-19 related disruptions will impact malaria cases and deaths in 2021 and beyond.