Malawi

Malaria facts

Malawi is among the top 20 countries with the highest malaria prevalence and mortality rates (2% of global cases and deaths). [1] About 7.4% of all malaria cases in Eastern and Southern Africa occur in Malawi. [1] Between 2016 and 2019, the case burden for malaria fell slightly from 211 to 208 per 1000 of the population at risk, while deaths fell by about 9% from 0.37 to 0.34 per 1000 of the population at risk. [1]

Prevalence and transmission

Malaria remains a major public health problem, accounting for 23% of all outpatient visits in all age groups. [2] In 2019 alone the country noted that 5.2 million cases (confirmed and presumed at 99.5% and 0.5% respectively) were reported from health facilities and the community case management programme. [2]

The incidence of malaria in Malawi has nonetheless declined by 26%, from 386 cases per 1000 population in 2016 to 286 per 1000 in 2019. [2] The rate of mortality from malaria has also fallen by 43% between 2015 and 2019 from 23 per 100,000 to 13 per 100,000 of the population at risk. What is more, malaria’s contribution to all causes of death has declined by 58%, from 36% in 2010 to 15% in 2019. [3]

Transmission is perennial in most parts of the country and peaks after the start of the annual rains that typically begin in November/December and last through April. The highest transmission areas are found along the hotter, wetter, and more humid low-lying areas (lakeshore, Shire River Valley and central plain), while the lowest risk areas fall along the highlands of Rumphi, Mzimba, Chitipa and Kirk Range. [3]

Plasmodium falciparum is the most predominant species of malaria in Malawi, accounting for 95% of malaria infections and all severe disease and deaths. Anopheles gambiae s.s, Anopheles funestus and Anopheles arabiensis are the major malaria vectors. [3]

Malawi’s healthcare system

The country’s health care system is organized within structures established at national, zonal, district and community levels. Public services provide 60% of health services and are free of charge; Christian Health Association Malawi (CHAM) provides 36% of services with malaria treatment services being at no charge. Private sectors facilities cater for 4% of services. [3] All of these systems offer malaria control services.[3] Tertiary health care centres, which consist of highly specialized services, manage severe malaria patients. [3]

Case management

A revision of the National Malaria Control Programme’s (NMCP’s) Guidelines for the Treatment of Malaria in Malawi was done in 2019. [2] For the management of patients with severe malaria, parenteral artesunate is recommended as the definitive treatment and as pre-referral intervention in health centers. Artesunate rectal capsules (ARC) are recommended pre-referral intervention for suspected severe malaria cases in children under five years of age at the community level. [5]

In 2019/2020, health workers were using the WHO Guidelines at the health facility and in community case management because the Malawi Guidelines were not up-to-date with the WHO Guidelines for the Treatment of Malaria, Fourth Edition (2021), A key difference between the Malawi Guidelines (2013) and the WHO Guidelines (2021) is the treatment of children weighing less than 20 kg with suspected severe malaria with a higher dose of injectable artesunate (3mg/kg) than larger children and adults (2.4 mg/kg). [5]

According to the 2017 Malaria Indicator Survey, 21% of patients with fever seek treatment in the private sector. The national policy allows testing and treatment to occur in the private sector; artemether–lumefantrine (AL) is the first line treatment with artesunate–amodiaquine (ASAQ) as a second line option. Dihydroartemisinin-piperaquine (DHA-PQP) is registered in Malawi and is estimated to comprise ~5–10% of treatments in the private sector. [5]

Uptake of interventions

Prevention of malaria in pregnancy

Uptake of the intermittent preventative treatment of malaria in Pregnancy has been gradually increasing in Malawi. However, uptake of the 3rd dose of IPTp remains low due to late initiation of antenatal care. The percentage of women receiving at least one dose of IPTp increased from 77% in 2012 to 92% 2017. [4] The percentage of women receiving IPTp3 increased from 13% in 2012 to 41% in 2017. [4]

The government is looking to increase uptake of at least 3 doses of IPTp through innovative interventions, which include the introduction of community based IPTp. [4]

Malaria among school children

Recent studies from Malawi reveal that primary schoolchildren have a high risk of Plasmodium infection, and a high prevalence of asymptomatic infections. To avert this situation, the government has introduced malaria case management in schools through the Learners Teachers Kit project in Zomba and Machinga.  In line with the updated national malaria strategic plan (2017-2022) Malawi will expand malaria case management programme to primary school children in selected schools in 4 districts in 2021. [2]

Insecticide Treated Nets (ITNs):

The percentage of households that own at least one insecticide-treated mosquito net (ITN) increased from 70% in the 2017 Malaria Indicator Survey (MIS) to 82 % in 2017. [5] However, the proportion of households that slept under an ITN the night before increased only slightly, from 53% to 55%. [5]

Between 2014–2017, ITN use also remained stagnant for children under 5 years of age (67% in 2014 and 68% in 2017) and for pregnant women (62% in 2014, 63% in 2017) [5]

Barriers to the uptake of interventions

Several cultural and social barriers, such as lack of equal access to resources by women, high female illiteracy, and household decision-making by males regarding the seeking of healthcare services, continue to restrict access to interventions by women and children. [5]

Severe malaria policy and practice

 

National treatment guidelines
Recommendation Treatment
Strong IV artesunate
Alternative IM artesunate
Alternative IV quinine
Recommendation Pre-Referral
Community level Rectal artesunate
Health facility  IM artesunate
Health facility alternative Rectal artesunate
Health facility alternative IM quinine
First trimester pregnancy
Recommendation Treatment
Strong IV quinine
Alternative IM quinine