Global response to malaria at crossroads WHO report shows gains are levelling

29 NOVEMBER 2017 | GENEVA - After unprecedented global success in malaria control, progress has stalled, according to the World malaria report 2017. There were an estimated 5 million more malaria cases in 2016 than in 2015. Malaria deaths stood at around 445 000, a similar number to the previous year.

“In recent years, we have made major gains in the fight against malaria,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. “We are now at a turning point. Without urgent action, we risk going backwards, and missing the global malaria targets for 2020 and beyond.”

The WHO Global Technical Strategy for Malaria calls for reductions of at least 40% in malaria case incidence and mortality rates by the year 2020. According to WHO’s latest malaria report, the world is not on track to reach these critical milestones.

A major problem is insufficient funding at both domestic and international levels, resulting in major gaps in coverage of insecticide-treated nets, medicines, and other life-saving tools.

Funding shortage

An estimated US$ 2.7 billion was invested in malaria control and elimination efforts globally in 2016. That is well below the US $6.5 billion annual investment required by 2020 to meet the 2030 targets of the WHO global malaria strategy.

In 2016, governments of endemic countries provided US$ 800 million, representing 31% of total funding. The United States of America was the largest international funder of malaria control programmes in 2016, providing US$1 billion (38% of all malaria funding), followed by other major donors, including the United Kingdom of Great Britain and Northern Ireland, France, Germany and Japan.

The global figures

The report shows that, in 2016, there were an estimated 216 million cases of malaria in 91 countries, up from 211 million cases in 2015. The estimated global tally of malaria deaths reached 445 000 in 2016 compared to 446 000 the previous year.

While the rate of new cases of malaria had fallen overall, since 2014 the trend has levelled off and even reversed in some regions. Malaria mortality rates followed a similar pattern.

The African Region continues to bear an estimated 90% of all malaria cases and deaths worldwide. Fifteen countries – all but one in sub-Saharan Africa – carry 80% of the global malaria burden.

“Clearly, if we are to get the global malaria response back on track, supporting the most heavily affected countries in the African Region must be the primary focus,” said Dr Tedros.

Controlling malaria

In most malaria-affected countries, sleeping under an insecticide-treated bednet (ITN) is the most common and most effective way to prevent infection. In 2016, an estimated 54% of people at risk of malaria in sub-Saharan Africa slept under an ITN compared to 30% in 2010. However, the rate of increase in ITN coverage has slowed since 2014, the report finds.

Spraying the inside walls of homes with insecticides is another effective way to prevent malaria. The report reveals a steep drop in the number of people protected from malaria by this method – from an estimated 180 million in 2010 to 100 million in 2016 – with the largest reductions seen in the African Region.

The African Region has seen a major increase in diagnostic testing in the public health sector: from 36% of suspected cases in 2010 to 87% in 2016. A majority of patients (70%) who sought treatment for malaria in the public health sector received artemisinin-based combination therapies (ACTs) – the most effective antimalarial medicines.

However, in many areas, access to the public health system remains low. National-level surveys in the African Region show that only about one third (34%) of children with a fever are taken to a medical provider in the public health sector.

Tackling malaria in complex settings

The report also outlines additional challenges in the global malaria response, including the risks posed by conflict and crises in malaria endemic zones. WHO is currently supporting malaria responses in Nigeria, South Sudan, Venezuela (Bolivarian Republic of) and Yemen, where ongoing humanitarian crises pose serious health risks. In Nigeria’s Borno State, for example, WHO supported the launch of a mass antimalarial drug administration campaign this year that reached an estimated 1.2 million children aged under 5 years in targeted areas. Early results point to a reduction in malaria cases and deaths in this state.

A wake-up call

“We are at a crossroads in the response to malaria,” said Dr Pedro Alonso, Director of the Global Malaria Programme, commenting on the findings of this year’s report. “We hope this report serves as a wake-up call for the global health community. Meeting the global malaria targets will only be possible through greater investment and expanded coverage of core tools that prevent, diagnose and treat malaria. Robust financing for the research and development of new tools is equally critical.”

1 in 10 medical products in developing countries is substandard or falsified WHO urges governments to take action

28 NOVEMBER 2017 | GENEVA - An estimated 1 in 10 medical products circulating in low- and middle-income countries is either substandard or falsified, according to new research from WHO.

This means that people are taking medicines that fail to treat or prevent disease. Not only is this a waste of money for individuals and health systems that purchase these products, but substandard or falsified medical products can cause serious illness or even death.

“Substandard and falsified medicines particularly affect the most vulnerable communities,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Imagine a mother who gives up food or other basic needs to pay for her child’s treatment, unaware that the medicines are substandard or falsified, and then that treatment causes her child to die. This is unacceptable. Countries have agreed on measures at the global level – it is time to translate them into tangible action.”

Since 2013, WHO has received 1500 reports of cases of substandard or falsified products. Of these, antimalarials and antibiotics are the most commonly reported. Most of the reports (42%) come from the WHO African Region, 21% from the WHO Region of the Americas, and 21% from the WHO European Region.

This is likely just a small fraction of the total problem and many cases may be going unreported. For example, only 8% of reports of substandard or falsified products to WHO came from the WHO Western Pacific Region, 6% from the WHO Eastern Mediterranean Region, and just 2% from the WHO South-East Asia Region.

“Many of these products, like antibiotics, are vital for people’s survival and wellbeing,” says Dr Mariângela Simão, Assistant Director-General for Access to Medicines, Vaccines and Pharmaceuticals at WHO. “Substandard or falsified medicines not only have a tragic impact on individual patients and their families, but also are a threat to antimicrobial resistance, adding to the worrying trend of medicines losing their power to treat”.

Prior to 2013, there was no global reporting of this information. Since WHO established the Global Surveillance and Monitoring System for substandard and falsified products, many countries are now active in reporting suspicious medicines, vaccines and medical devices. WHO has trained 550 regulators from 141 countries to detect and respond to this issue. As more people are trained, more cases are reported to WHO.

WHO has received reports of substandard or falsified medical products ranging from cancer treatment to contraception. They are not confined to high-value medicines or well-known brand names and are split almost evenly between generic and patented products.

In conjunction with the first report from the Global Surveillance and Monitoring System published today, WHO is publishing research that estimates a 10.5% failure rate in all medical products used in low- and middle-income countries.

This study was based on more than 100 published research papers on medicine quality surveys done in 88 low- and middle-income countries involving 48 000 samples of medicines. Lack of accurate data means that these estimates are just an indication of the scale of the problem. More research is needed to more accurately estimate the threat posed by substandard and falsified medical products.

Based on 10% estimates of substandard and falsified medicines, a modelling exercise developed by the University of Edinburgh estimates that 72 000 to 169 000 children may be dying each year from pneumonia due to substandard and falsified antibiotics. A second model done by the London School of Hygiene and Tropical Medicine estimates that 116 000 (64 000 – 158 000) additional deaths from malaria could be caused every year by substandard and falsified antimalarials in sub-Saharan Africa, with a cost of US$ 38.5 million (21.4 million – 52.4 million) to patients and health providers for further care due to failure of treatment.

Substandard medical products reach patients when the tools and technical capacity to enforce quality standards in manufacturing, supply and distribution are limited. Falsified products, on the other hand, tend to circulate where inadequate regulation and governance are compounded by unethical practice by wholesalers, distributors, retailers and health care workers. A high proportion of cases reported to WHO occur in countries with constrained access to medical products.

Modern purchasing models such as online pharmacies can easily circumvent regulatory oversight. These are especially popular in high-income countries, but more research is needed to determine the proportion and impact of sales of substandard or falsified medical products.

Globalization is making it harder to regulate medical products. Many falsifiers manufacture and print packaging in different countries, shipping components to a final destination where they are assembled and distributed. Sometimes, offshore companies and bank accounts have been used to facilitate the sale of falsified medicines.

“The bottom line is that this is a global problem,” says Dr Simão. “Countries need to assess the extent of the problem at home and cooperate regionally and globally to prevent the traffic of these products and improve detection and response.”

Note to editors

WHO is publishing two reports today:

WHO launched its Global Surveillance and Monitoring System for substandard and falsified medicines, vaccines and in-vitro diagnostic tests in July 2013. This first report is based on data collected during the first 4 years of operation up to 30 June 2017.
A study on the public health and socioeconomic impact of substandard or falsified medical products conducted by WHO and the Member State Mechanism.
This study is based on 100 literature reviews and two peer-reviewed models developed by the University of Edinburgh and The London School of Hygiene and Tropical Medicine. The 100 papers reviewed provide data for more than 48 000 samples of medicines from 88 countries. Because only 178 samples were taken in high-income countries, prevalence estimates of substandard or falsified medical products were limited to low- and middle-income countries.

Despite these limitations, these two reports represent the most comprehensive compilation to date of data related to substandard and falsified medical products and are a first step towards better understanding their public health and socioeconomic impact.