The third "i": implement

Malaria-affected countries and partners are strongly encouraged to deliver the WHO-recommended tools and strategies that are available now for all at risk of malaria – and particularly those most vulnerable.

According to the latest World malaria report, countries have made some progress in expanding access to malaria services for most-at-risk populations:

• In 2021, nearly 45 million children were reached with seasonal malaria chemoprevention (SMC) in 15 African countries, a major increase from 33.4 million in 2020 and about 22 million in 2019. The preventive therapy is recommended for children living in areas with highly seasonal malaria transmission in Africa.
• Based on household surveys, the proportion of febrile children in sub-Saharan Africa who were taken to a health provider and tested for malaria increased considerably between the periods 2005–2011 and 2015–2021, rising from a median of about 30% to 57%.
• To date, more than 1.3 million children have been reached with at least 1 dose of the RTS,S malaria vaccine in 3 African countries: Ghana, Kenya and Malawi. A further 29 countries in Africa have expressed interest in adopting the malaria vaccine as part of their national malaria control strategies. The vaccine was recommended by WHO in October 2021 to prevent malaria among young children living in regions with moderate-to-high falciparum malaria transmission.

However, too many people at high risk of malaria are still missing out on the services they need to prevent, detect and treat the disease. According to the World malaria report 2022:

• Just over half (53%) of children under 5 years of age and pregnant women in sub-Saharan Africa slept under an insecticide-treated net (ITN) in 2021.
• Only one third (35%) of pregnant women received the WHO-recommended 3-dose regimen of intermittent preventive therapy in 2021 – a figure that has remained largely unchanged in recent years.
• About one third of children with a fever (35%) were not taken to a health provider for any form of care or treatment, based on household surveys in sub-Saharan Africa conducted between 2015 and 2021, and poorer households were less likely to seek care for their febrile child. Less than 1% of children access treatment from community health workers.
• In the face of high demand for the malaria vaccine initial supply is limited, thereby limiting the impact that can be achieved.

Challenges in expanding access to malaria services have been compounded, particularly in sub-Saharan Africa, by the ongoing COVID-19 pandemic, converging humanitarian crises, restricted funding, weak surveillance systems, and declines in the effectiveness of core malaria-fighting tools.

• As described in the World malaria report 2022, the most commonly used ITNs, which are treated with one only insecticide class (pyrethroids), are becoming less effective in controlling the disease. Threats to this key prevention tool include insecticide resistance, insufficient access, loss of ITNs due to the stresses of day-to-day use outpacing replacement and changing behaviour of mosquitoes.
• In some areas, malaria parasites are escaping detection by rapid diagnostic tests, presenting a major threat to early diagnosis and treatment.
• Other threats to the malaria response in the African continent include growing parasite resistance to antimalarial drug regimens and an invasive mosquito that adapts easily to urban environments.

To address these threats and support countries in building more resilient malaria programmes, WHO recently published new guidance, including:

• a new strategy to contain antimalarial drug resistance in Africa;
• a new initiative to stop the spread of Anopheles stephensi in urban environments;
• a new framework, developed jointly by WHO and UN-Habitat, to guide city leaders in urban malaria control.
• a new toolkit to help countries assess their malaria surveillance systems and identify areas for investment

To support malaria-endemic countries, WHO has also increased the transparency, flexibility and access to its malaria recommendations. WHO encourages countries to tailor the recommendations to local disease settings, using local data, for maximum impact. All WHO malaria guidance is available through two digital platforms:

•  MAGICapp – The consolidated WHO guidelines for malaria are accessible through the MAGICapp platform in English, French, Arabic and Spanish;
  
•  Malaria Toolkit app – WHO’s most up-to-date recommendations on malaria can also be found in the Malaria Toolkit app.

WHO’s consolidated guidelines are a “living” document that is updated periodically as and when new guidance becomes available. In June 2022, WHO updated its recommendations for 3 key chemoprevention strategies.

1. Seasonal malaria chemoprevention (SMC) is recommended for children living in areas with highly seasonal malaria transmission in Africa.
2. Perennial malaria chemoprevention (PMC) is recommended for young children living in areas where malaria is a year-round disease, and where transmission is high.
3. Intermittent preventive treatment of malaria in pregnancy (IPTp) is recommended for all pregnant women living in areas of moderate-to-high malaria transmission in Africa.

When given to the young children and pregnant women who are most vulnerable to malaria, preventive chemotherapy has been shown to be a safe, effective and cost-effective strategy for reducing the disease burden and saving lives.

WHO recently published recommendations on new types of insecticide-treated nets (March 2023) and on the treatment of malaria cases (November 2022).