Anti-malaria tools have changed during a life’s work battling malaria
Since 1981, when Leo Makita started working against malaria in Papua New Guinea as a way to pay for his graduation gown, he has overseen a major shift in tactics, away from indoor residual spraying to bednets.
The mosquito net that has cut malaria’s threat to Papua New Guinea (PNG) is a simple tool, but the path required to achieve its widespread use has been anything but simple for public health workers like Leo Makita.
Born in PNG, he earned a Diploma in entomology, parasitology and microbiology in Kuala Lumpur, then earned a degree in public health from the Liverpool School of Tropical Medicine. But before all that schooling, Makita had already embarked on what was to become his life’s work: he joined the country’s malaria control programme just after graduating from the University of PNG in 1981. “I needed some money to pay for my graduation gown,” he said in a telephone interview last month from Geneva, where he was attending a meeting of WHO’s Malaria Policy Advisory Committee.
He got it – and more. Makita has overseen a major shift in the tactics used to fight malaria, which were then centered on spraying the interior walls of dwellings with insecticides, known as indoor residual spraying (IRS). The government-run vertical programme was separated from other health services and administered from Port Moresby, the capital city where he is based. It was massive. “They had people employed in every province – sprayers , team leaders, microscopists, entomology teams, you name it.”
After entomologists identified the mosquitoes responsible for malaria transmission, teams conducted house-to-house spraying. But spraying ceased in the mid-1980s, as costs rose and its effectiveness declined. The insecticides had caused the mosquitoes to change their biting patterns. And the parasites had begun developing resistance to chloroquine, one of the workhorse anti-malarial drugs.
A shift away from indoor residual spraying
In the late 1980s, the government integrated the anti-malaria programme into the country’s general health services. Cutbacks in malaria staffing and funding followed. “Malaria control was more or less dead,” said Makita. In the 1990s, the Institute of Medical Research in PNG carried out studies that looked at the impact on malaria of nets dipped into the insecticide permethrin. “Results showed there was a lot of protective effect,” Makita said. But the nets needed to be re-treated every six months – a major drawback in a country like PNG, where most of the population at high risk of malaria can be reached only by helicopter.
That problem was overcome around 2000, when long-lasting insecticidal nets, or LLINs, were developed and proved effective for 3 years. In 2003, the Global Fund began paying for nets for everyone who needed one, and for their delivery to people in often remote areas. Their impact was huge.
“Our challenge now is to maintain those gains that we have made and even reduce cases further.”
Leo Makita, PNG National Malaria Control Programme
Together with the preventive measures of LLIN distribution, PNG’s treatment policy was changed to the more effective artemisinin-based combination therapy. Rapid diagnostic tests were introduced country-wide, enabling accurate diagnosis and prompt treatment.Mass distribution of LLINs, RDTs and effective treatment has seen massive reductions in malaria morbidity and mortality.
“Our challenge now is to maintain those gains that we have made and even reduce cases further,” Makita said. “Funding is our major problem at the moment.” The 80%-90% coverage in mosquito nets that had been achieved cannot be maintained in the face of the cutbacks, he said. “We need to now be very selective.” That may mean that residents of urban areas, where many people can afford to pay for their nets, will stop getting them free, he said.
Travel to a health center can take a week
The funds will instead be focused on people in areas with a high burden of malaria and few resources. People in remote, rural locations often have limited access to health services. For them, preventive tools like nets can save money – and lives.
“If they are sick, it may mean a whole day’s walk or maybe a week’s walk. Obviously, people will be too sick to actually get to a facility. That’s where people lose their lives.” Makita’s experience goes beyond what he learned in school. When he first started working in the field, he wound up with cerebral malaria but did not move quickly to treat it and suffered seizures. “I nearly even went into a coma.”
Since then, he has gotten malaria twice more, but now he responds quickly. “I get myself treated as early as possible.”