World malaria report 2022

What impact has the COVID-19 pandemic had on malaria cases and deaths?

At the beginning of the pandemic, there were concerns that malaria services could be disrupted so severely that 20 years of gains against the disease would be lost. Concerted action by countries and their national malaria programmes (NMPs), with support from WHO and global partners and donors, ensured that this worst-case scenario was prevented. However, the COVID-19 pandemic still caused considerable service disruptions resulting in increases in the malaria burden in many countries.

Globally, the number of malaria deaths fell between 2020 and 2021 from 625 000 to 619 000 but remained higher than the estimated 568 000 malaria deaths in 2019 before the pandemic struck. Malaria cases continued to rise in 2021, but at a slower rate compared to the period 2019–2020: cases stood at an estimated 247 million in 2021, 245 million in 2020 and 232 million in 2019.

Looking across the 2 peak years of the pandemic, our report shows that the cumulative impact of the COVID-19 pandemic was considerable. In 2020 and 2021, a total of about 63 000 additional malaria deaths and 13 million cases can be attributed to COVID-related disruptions, with the vast majority of these in the WHO African Region.

What does the report say about trends in countries with a high burden of malaria?

Eleven countries with the highest burden of malaria globally largely held the line against malaria during the pandemic: Burkina Faso, Cameroon, the Democratic Republic of the Congo, Ghana, India, Mali, Mozambique, the Niger, Nigeria, Uganda and the United Republic of Tanzania. Malaria deaths in these countries fell from an estimated 444 600 in 2020 to 427 854 in 2021, while cases increased from 165 million to 168 million in this same timeframe.

Five of these countries showed a decline in deaths in 2021 compared to 2020: the Democratic Republic of the Congo, Ghana, India, the Niger and the United Republic of Tanzania. However, their contribution to the malaria burden was still substantial.

What about countries with a low burden of malaria? How did they fare?

Many countries with a low burden of malaria also succeeded in maintaining effective malaria responses during the pandemic and continued their drive towards elimination.

Between 2020 and 2021, 4 countries – Belize, Cabo Verde, the Islamic Republic of Iran and Malaysia – were able to maintain zero indigenous cases of the main human malaria parasites. All of these countries are part of the “E-2025”, a WHO initiative aimed at supporting a group of low-burden countries in eliminating the disease.

In this same timeframe, reductions in malaria cases were observed in Bhutan (59.1%), Botswana (20.5%), the Dominican Republic (65.6%), Mexico (32%), Nepal (56.2%), the Republic of Korea (23%), Saudi Arabia (100%), South Africa (33.7%), Suriname (85.9%), Thailand (22.3%), Timor-Leste (100%) and Vanuatu (36.7%).

There were, however, notable case increases in several countries, including the Comoros (56.9%), Costa Rica (52.4%), the Democratic People’s Republic of Korea (22.8%), Ecuador (11.1%), Eswatini (53.9%), French Guyana (2.1%), Guatemala (16.9%), Honduras (47.4%), Panama (55.3%) and Sao Tome and Principe (28.9%).

Are countries in the Greater Mekong subregion continuing to see progress?

Countries in this subregion maintained steady progress in driving down cases caused by P. falciparum malaria parasites, with a 12% decline between 2020 and 2021. This decline is notable in view of the threat posed by antimalarial drug resistance in the subregion. In recent years, P. falciparum parasites have developed partial resistance to artemisinin – the core compound of artemisinin-based combination therapies (ACTs). In some areas, they have also developed resistance to the partner drugs within ACTs.

Despite the decline in P. falciparum, indigenous malaria cases overall increased by about 17% between 2020 and 2021 in the subregion, mainly due to P. vivax malaria. Myanmar accounted for most of this increase, as political instability added disruption to the national malaria control programme.

Did any countries eliminate malaria during the pandemic?

Even during the pandemic year of 2021, 2 countries – China and El Salvador – were certified malaria free after achieving 4 years of zero indigenous malaria cases. Currently, malaria-free certification is pending for 5 more countries: Azerbaijan, Belize, Cabo Verde, the Islamic Republic of Iran and Tajikistan.

As seen year after year, good malaria control can wipe out malaria, making a vast difference in population health and improving a country’s prospects for economic development.

How were preventive, diagnosis and treatment services impacted by the pandemic?

The impact varied across countries and interventions. For several interventions, malaria-endemic countries were able to reduce pandemic impacts and, in a few cases, begin recovering lost ground.

In 2020 and 2021, for example, about three quarters of the insecticide treated nets (ITNs) that had been planned for distribution reached target communities.

Countries continue to make excellent progress in scaling up seasonal malaria chemoprevention (SMC); in 2021, nearly 45 million children, on average, were reached per SMC cycle in 15 African countries compared to 33.4 million in 2020 and 22.1 million in 2019.

Meanwhile, coverage of intermittent preventive treatment in pregnancy (IPTp) remained stable. In 2021, an estimated 35% of pregnant women in 35 African countries received a full 3-dose regimen of IPTp compared to 32% in 2020. Despite the declining use of antenatal care services since the onset of the pandemic, IPTp coverage in 2021 was similar to the level seen in 2019.

Most countries succeeded in implementing high levels of malaria diagnostic testing despite pandemic-related disruptions, especially in 2020. Globally, an estimated 833 million tests were performed during the 2 peak years of COVID-19 (2020–2021) compared to 842 million in the 2 preceding years (2018–2019).

Countries also held the line in providing access to artemisinin-based combination therapies (ACTs), the best available medicines for treating malaria. In 2021, malaria-endemic countries distributed 242 million ACTs globally (97% in sub-Saharan Africa) compared to 260 million in 2020 and 239 million ACT distributions in 2019.

How has the risk landscape for malaria control changed from before the pandemic?

Although direct COVID-19 disruptions have lessened in 2021 in many countries, the cumulative impacts of the prolonged pandemic continue to weigh on the economies and health systems of malaria-endemic countries. Additional risks brought on by changing socioeconomic conditions, biological shifts in the malaria parasite and its mosquito vectors, and a decline in the effectiveness of core malaria control tools make the coming period crucial for regaining control of malaria.

Major socioeconomic factors continue to disrupt essential health services and limit the capacity of health systems. In addition, humanitarian crises over the last 3 years due to conflicts, famine, flooding and other health emergencies in 37 malaria-endemic countries affected hundreds of millions of people. In each of these countries, malaria increases occurred above what could be attributed to the COVID-19 pandemic alone.

Biological risks are also rising as mosquitos that transmit malaria are developing resistance to the insecticides used to repel or kill them. In addition, genetic mutations in some malaria parasites are making them less visible to commonly used rapid diagnostic tests, and more resistant to artemisinin, the major drug component of ACT regimens for malaria. In the Greater Mekong, resistance to some partner drugs within ACTs has also been confirmed. Meanwhile, a new urban-adapted mosquito species that transmits malaria has begun to spread in Africa.

As a result of these and other challenges, including inadequate funding, the effectiveness of some of our primary malaria control interventions is declining. This is especially true of pyrethroid-only insecticide-treated nets (ITNs), which have been the bedrock of the malaria response for 20 years. 

All of these risks raise serious concerns for national malaria programmes and global partners seeking to control and eliminate malaria.

What about the funding landscape?

In 2020, the United States Government provided a US$ 3.7 billion emergency contribution to the Global Fund to support the launch of the COVID-19 Response Mechanism (C19RM). C19RM supported the pandemic-related adaptation of programmes to fight HIV, TB and malaria. The delivery of COVID supplies such as masks and gloves, for example, became an opportunity to also deliver malaria medicines and ITNs.

Nonetheless, we will need a lot more funding to reach our global malaria goals. Malaria investment in 2021 was US$3.5 billion against a target of $US 7.3 billion in the WHO Global technical strategy for malaria 2016–2030. The overall funding gap is large and growing – increasing from US$ 2.6 billion in 2019 to US$ 3.5 billion in 2020 and US$ 3.8 billion in 2021.

In 2021, 40% of global malaria investments were channeled through the Global Fund. Despite the historic contributions by countries and partners in 2022, the US$ 15.7 billion raised by the Seventh Global Fund replenishment fell short of the target of at least US$18 billion. With the changing economic environment, the funding space for the malaria response has become increasingly challenging.

At the international level, the World Bank recently established a Financial Intermediary Fund (FIF), with technical leadership by WHO. The fund aims to support low- and middle-income countries in pandemic prevention, preparedness, and response. Building stronger and more resilient health systems is an important part of the FIF’s work programme and, to this end, the resilience of a primary health care system (PHC) that addresses major killer diseases such as malaria are likely to benefit.

How serious are threats to the effectiveness of insecticide-treated nets (ITNs)?

The main threats are the rise of insecticide resistance in the mosquitoes that transmit malaria and the physical and chemical durability and retention of the ITNs by households. The vast majority of the 2.5 billion ITNs distributed between 2004 and 2021 have been treated with a single insecticide class, pyrethroids. Contact with pyrethroid-treated nets repels and kills mosquitoes.

Although highly variable by setting, the median retention time of current ITNs by household in sub-Saharan Africa is about 1.9 years, yet community mass campaigns normally happen every 3 years. This means that a considerable proportion of the population remain without effective protection for a considerable period of time. Continuous distributions to cover infants and pregnant women as well as distribution through schools help, but they may not cover all of the gap in protection between campaigns. 

Other factors impacting the effectiveness of ITNs include inadequate use and changing behaviour of mosquitoes, which appear to be biting early before people go to bed, and resting outdoors, thereby evading exposure to insecticides.

All of these threats and challenges are serious and need an appropriately strong response to ensure that ITNs continue to provide the maximum possible benefit in fighting malaria. However, ITNs remain the most effective and scalable vector control tool available to limit the spread of malaria in moderate-to-high transmission settings, and their continued use as a pillar of malaria control is essential.

What can be done to preserve ITN effectiveness?

ITN distribution campaigns already use a larger proportion of dual ingredient nets treated with both pyrethroid and the synergist piperonyl butoxide (PBO). Such PBO nets have shown to be more effective than pyrethroid-only nets in lowering parasite prevalence, but do not provide a long-term means of managing pyrethroid resistance.

In 2021, 46% of the 220 million ITNs delivered were PBO nets (25% more than in 2020), with plans for further scale-up. However, like conventional pyrethroid-only ITNs, these new nets can be compromised both by their physical and chemical durability when in active use, and household behaviours related to care for the nets remain challenging.

Another promising insecticide combination is that of 2 different insecticide classes: a pyrethroid and the pyrrole chlorfenapyr. Ongoing field trials of nets treated with these 2 active ingredients have shown them to be more effective than pyrethroid-only nets in preventing malaria.

There is now accelerated Research and Development (R&D) into new insecticide treatments and combinations and a focus on improved communications with communities about best ITN care and use; improved delivery and distribution of ITNs in higher risk settings; and more localized attention to coverage needs, including research into assessing the effectiveness of delivery channels other than campaigns. 

In view of the various challenges of measuring ITN durability, the WHO Prequalification Department is leading an effort to develop updated guidelines for assessing the quality of ITNs, including specifications for monitoring the physical durability of nets.

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

The WHO Global technical strategy for malaria 2016–2030 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. 

Globally in 2021, malaria case incidence was 59 cases per 1000 population at risk, against a target of 31 – off track by 48%. Malaria deaths per 100 000 population at risk stood at 14.8 in 2021 against a target of 7.8 – also off track by 48%. If this trajectory continues, by 2030 the world will be off track in reaching the malaria targets by 88%.

With all the competing demands on country’s budgets, why should malaria be a priority?

Malaria is an acute disease and a classic maternal and child health disease. About 80% of malaria deaths are among children under the age of 5, and most of the remaining deaths occur in children under the age of 10 and pregnant women.

If a person infected with malaria is not immune and not treated, he or she is likely to die quickly. In some countries, malaria is responsible for up to 40% of health care visits, including hospital admissions. As such, malaria has a huge health, social and economic toll.

As the Director General of WHO, Dr Tedros Ghebreyesus often says, health is not a cost but an investment, and there is ample evidence that the control and elimination of malaria has a massive return on investment.

Investments in malaria control have averted nearly 12 million deaths and 2 billion cases since 2000, representing one of the great global public health success stories of recent years. Most of this success has occurred in the WHO African Region, even though it still accounts for over 95% of the malaria burden globally and is beset by many challenges in its malaria response.

What are the biggest opportunities to get back on track and advance malaria control and elimination?

There are 5 main opportunities:

The first is for National Malaria Programmes to continue to make smart use of the toolbox of malaria control interventions, tailored to their own national and local conditions, and to incorporate improved products as they become available, whether those are ITNs or vaccines. Strengthening of routine disease surveillance systems, efficacy studies and post-market surveillance of malaria commodities is essential to monitoring and responding to issues around quality and effectiveness.

New WHO guidelines and strategies offer in-depth recommendations to address rising challenges and opportunities. The updated WHO Guidelines for malaria, for example, provide a framework for incorporating RTS,S, the world’s first malaria vaccine, into national malaria control plans.

WHO recently published new strategies to curb antimalarial drug resistance and to stop the spread of an invasive malaria vector in the African continent. There is also a new global framework to help countries respond to malaria in urban settings.

The second is to ambitiously pursue the research and development of products that will strengthen prevention, control transmission and treat disease. These include new insecticides, new strategies for outdoor vector control, vaccine candidates, new diagnostics, and innovations in drugs and drug combinations.

Meanwhile, vaccine research is producing new candidates. In 2021, WHO recommended the use of RTS,S, making it the first-ever vaccine approved against malaria, and its roll-out has begun. A second vaccine, R21, the most advanced vaccine in development, has completed Phase 3 clinical trials. Also in development are 10 vaccines against P. falciparum, 4 against P. vivax, and 2 for use during pregnancy.

The third, as stated above, is to ramp up funding to ensure national malaria control and elimination strategies are effectively implemented, even in difficult circumstances, so that all those in need can benefit from existing interventions and promising new tools. More resources must be mobilized, particularly from domestic sources.

The fourth is to strengthen primary health care (PHC) through a radical reorientation of health systems, which currently focus primarily on treating disease rather than on preventing it. PHC is the foundation for strengthening the resilience of health systems to meet a wide range of shocks, particularly at a time when global financial resources for health and malaria are constrained. Health systems anchored in strong primary health care services provide more appropriate, effective and less costly care, as well as greater service coverage.

The fifth is to reignite the malaria response with a greater focus on country leadership and ownership. Over 95% of the burden of malaria is in the WHO African region, and we must acknowledge the need for strong African leadership and a broader coalition within Africa to tackle malaria, recognizing the benefits of a PHC approach and a commitment to social justice and equity. This is consistent with WHO’s strategic priority to accelerate progress on universal health coverage.