World Malaria Report 2018: Quick blueprint for action, no standing still

December 27, 2018

No standing still with malaria, fighting the disease must continue or progress can be quickly lost. Still from WHO film on World Malaria Report 2018 call to action.

No standing still with malaria, fighting the disease must continue or progress can be quickly lost. Still from WHO film on World Malaria Report 2018 call to action.

World Health Organization’s (WHO) World Malaria Report 2018 dropped on November 19, a month earlier than usual (but about the same time as 2017). With an additional few weeks to plug it, it still sank without big ripples in world media.

WHO adds a shorter version, an “executive version” — that still doesn’t get the attention it should.

This is prelude to a tragedy if industrialized and wealthy nations of the world pay no heed, and continue to cut budgets to fight malaria for whatever bad reason some crabby, brown Earth policy maker invents.

Ever optimistic, WHO gives a plan for action to continue to reduce malaria deaths and infections, even with reduced funding. None of the proposed actions involves more DDT to poison poor people in poor countries, however, so it is unlikely to find favor with the crabby policy people now in charge of fixing world problems in the increasingly isolationist West (including the U.S.).

Please watch the video. What is your country doing to eradicate malaria? How can you prod politicians to do more?
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World Malaria Report 2018: World looks away as malaria bounces back

December 7, 2018

Covers of the last four World Malaria Reports. World Health Organization (WHO)

Covers of the last four World Malaria Reports. World Health Organization (WHO)

It’s a common tale but true: In any period when nations collaborate to defeat or eradicate malaria, funders of the programs get board and cut funding.

Malaria roars back.

This cycle has nothing to do with pesticides or medicines, mostly. Especially it’s not a problem that can be fixed with more DDT.

When a nation focuses on beating malaria, progress occurs. When nations lose their focus, malaria strikes back.

After great progress reducing malaria infections and malaria deaths between 1999 and 2017, nations including the U.S. lost focus. International donors failed to contribute enough money to keep the fight going.

World Malaria Report 2018 notes the striking back by malaria.

One other thing we can be quite sure of: Almost all mass media will ignore this report.

What will you do to change things?

You can help by donating $10 to a charity that delivers bednets to people who need them in Asia and Africa. You can help by writing letters to your local newspapers, to your Congressional representatives, and to the President. Every little bit helps.

Here’s the press release on World Malaria Report 2018, which was released by the World Health Organization (WHO) on November 19, 2018.

WHO and partners launch new country-led response to put stalled malaria control efforts back on track

19 November 2018
News Release

Maputo/Geneva

Reductions in malaria cases have stalled after several years of decline globally, according to the new World malaria report 2018. To get the reduction in malaria deaths and disease back on track, WHO and partners are joining a new country-led response, launched today, to scale up prevention and treatment, and increased investment, to protect vulnerable people from the deadly disease.

For the second consecutive year, the annual report produced by WHO reveals a plateauing in numbers of people affected by malaria: in 2017, there were an estimated 219 million cases of malaria, compared to 217 million the year before. But in the years prior, the number of people contracting malaria globally had been steadily falling, from 239 million in 2010 to 214 million in 2015.

“Nobody should die from malaria. But the world faces a new reality: as progress stagnates, we are at risk of squandering years of toil, investment and success in reducing the number of people suffering from the disease,” says Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “We recognise we have to do something different – now. So today we are launching a country-focused and -led plan to take comprehensive action against malaria by making our work more effective where it counts most – at local level.”

Where malaria is hitting hardest

In 2017, approximately 70% of all malaria cases (151 million) and deaths (274 000) were concentrated in 11 countries: 10 in Africa (Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and United Republic of Tanzania) and India. There were 3.5 million more malaria cases reported in these 10 African countries in 2017 compared to the previous year, while India, however, showed progress in reducing its disease burden.

Despite marginal increases in recent years in the distribution and use of insecticide-treated bed nets in sub-Saharan Africa – the primary tool for preventing malaria – the report highlights major coverage gaps. In 2017, an estimated half of at-risk people in Africa did not sleep under a treated net. Also, fewer homes are being protected by indoor residual spraying than before, and access to preventive therapies that protect pregnant women and children from malaria remains too low.

High impact response needed

In line with WHO’s strategic vision to scale up activities to protect people’s health, the new country-driven “High burden to high impact” response plan has been launched to support nations with most malaria cases and deaths. The response follows a call made by Dr Tedros at the World Health Assembly in May 2018 for an aggressive new approach to jump-start progress against malaria. It is based on four pillars:

  • Galvanizing national and global political attention to reduce malaria deaths;
  • Driving impact through the strategic use of information;
  • Establishing best global guidance, policies and strategies suitable for all malaria endemic countries; and
  • Implementing a coordinated country response.

Catalyzed by WHO and the RBM Partnership to End Malaria, “High burden to high impact” builds on the principle that no one should die from a disease that can be easily prevented and diagnosed, and that is entirely curable with available treatments.

“There is no standing still with malaria. The latest World malaria report shows that further progress is not inevitable and that business as usual is no longer an option,” said Dr Kesete Admasu, CEO of the RBM Partnership. “The new country-led response will jumpstart aggressive new malaria control efforts in the highest burden countries and will be crucial to get back on track with fighting one of the most pressing health challenges we face.”

Targets set by the WHO Global technical strategy for malaria 2016–2030 to reduce malaria case incidence and death rates by at least 40% by 2020 are not on track to being met.

Pockets of progress

The report highlights some positive progress. The number of countries nearing elimination continues to grow (46 in 2017 compared to 37 in 2010). Meanwhile in China and El Salvador, where malaria had long been endemic, no local transmission of malaria was reported in 2017, proof that intensive, country-led control efforts can succeed in reducing the risk people face from the disease.

In 2018, WHO certified Paraguay as malaria free, the first country in the Americas to receive this status in 45 years. Three other countries – Algeria, Argentina and Uzbekistan – have requested official malaria-free certification from WHO.

India – a country that represents 4% of the global malaria burden – recorded a 24% reduction in cases in 2017 compared to 2016. Also in Rwanda, 436 000 fewer cases were recorded in 2017 compared to 2016. Ethiopia and Pakistan both had estimated decreases of more than  240 000 in the same period.

“When countries prioritize action on malaria, we see the results in lives saved and cases reduced,” says Dr Matshidiso Moeti, WHO Regional Director for Africa. “WHO and global malaria control partners will continue striving to help governments, especially those with the highest burden, scale up the response to malaria.”

Domestic financing is key

As reductions in malaria cases and deaths slow, funding for the global response has also shown a levelling off, with US$ 3.1 billion made available for control and elimination programmes in 2017 including US$ 900 million (28%) from governments of malaria endemic countries.  The United States of America remains the largest single international donor, contributing US$ 1.2 billion (39%) in 2017.

To meet the 2030 targets of the global malaria strategy, malaria investments should reach at least US$6.6 billion annually by 2020 – more than double the amount available today.

Editors note

Download the WHO World malaria report 2018 app for an interactive experience with the report’s country data: App Store (iOS devices) | Google Play (Android devices).


‘DDT has become harmless to mosquitoes today’

March 29, 2018

From India today, not news to anyone who follows the fight against malaria, and the fight to save a part of the planet to preserve human life.

DDT resistance prompted India to agree to stop production of DDT by 2020 — the last DDT factory remaining. India’s disease fighters tell of frustration trying to control malaria, because abuse of DDT has bred DDT resistant and immune mosquitoes. This is not news.

But India Today has a news hole to fill, and the continuing crises of vector-borne diseases force public health agencies to turn to “fourth generation” pesticides, as insects are now resistant to DDT and malathion.

The story out of New Delhi on March 13 almost adds some poetry to the issue. I repeat the story from India Today in full, partly because I love the lilt of Indian English, and because it tells the story of continuing attempts to get ahead of pesticide resistance in pests, attempts that just don’t seem to be doing the job.

Delhi’s civic agencies asked to use fourth generation pesticides to kill chemical-resistant insects

A small vehicle fogging streets of Delhi, India, with DDT, to fight mosquitoes. File photo from India Today, used to illustrate the story only.

A small vehicle fogging streets of Delhi, India, with DDT, to fight mosquitoes. File photo from India Today, used to illustrate the story only.

Pesticides such as DDT and malathion, which were once super weapons in the fight against mosquitoes, now seem to have become harmless perfume-like sprays for the blood-sucking parasites.

Scientists at the National Vector Borne Disease Control Programme (NVBDCP), Delhi which is the central nodal agency for prevention of diseases like malaria, dengue, filariasis, kala-azar, Japanese encephalitis and chikungunya, etc, in India has now recommended municipalities in the Capital and other parts of the country to shift to the 4th generation of pesticides that is also the last in the row.

These constitute certain bio-larvicides and insect growth regulators that stop the synthesis of critical hormones in mosquito larvae to prevent them from becoming adult. Only after attaining maturity, do the female Anopheles and Aedes Aegypti mosquitoes suck blood to get protein nutrition to lay eggs.

Scientists explain that the first generation of pesticides was DDT, used since World War II on soldiers in 1940s up till now, as its a powerful poison against mosquitoes. Later, its environmental effects, specifically on birds like vultures, reduced its usage globally.

Then came malathion, which had to be applied in huge quantities, paving the way for 3rdgeneration pesticides like synthetic pyrethroids and temephos. But with reports of mosquitoes developing tolerance towards all of these gradually, scientists are now recommending mixed and increased usage of the fourth generation of pesticides that is also the last line of defence in this class.

Experiments are still going on with genetically modified mosquitoes and introducing batches of mosquitoes injected with wolbachia bacteria in the wild to produce sterile eggs. A senior scientist with the NVBDCP, Civil Lines, said, Just like humans develop resistance towards antibiotics, mosquitoes have also evolved over the past 20-30 years to grow natural defence against DDT, malathion, etc. We are still using these two in virgin areas like forests of northeast India, Odisha, etc. successfully. But we have begun getting reports that even temephos and synthetic pyrethroids have stopped receiving the desired results against mosquitoes.

A pesticide is said to be successful when it kills over 90 per cent of the targeted insect or pest population. Over 3,500 species of mosquitoes, which play host to a number of disease-causing vectors such as zika, yellow fever, west Nile virus, etc. are said to be the deadliest animal family in the world. They kill 700 million people annually world over.
In Delhi itself, at least 10 people died of dengue last year and 9,271 people were affected.

The numbers of malaria and chikungunya cases recorded in 2017 stood at 1,142 and 940. In 2016, at least 21 dengue deaths were reported from various city hospitals. And this year, an early onset of the deadly trio dengue, malaria and chikungunya is expected with summer-like weather conditions already.

High temperature and presence of clear water in desert coolers, flower pots, coconut shells, etc, act as excellent breeding sites for the menacing insects.

We have asked municipalities to even use the fourth generation of pesticides pirimiphos-methyl and diflubenzuron in a mix with the previous generation pesticides to delay mosquitoes developing tolerance towards this in the future, the scientist explained. He said, over the years, the pesticides must be rotated in use so that their effectiveness on hardy mosquitoes does not go down.

Dr Himmat Singh, senior scientist at the National Institute of Malaria Research (NIMR), Dwarka, said, The benefit with these two latest pesticides is that they are only hormone-inhibitors, not poisons, and specific to mosquitoes. So they wouldnt have any effect on other insects, birds, mammals, fishes, etc. They are categorised as non-hazardous by WHO. However, their cost has been prohibitive so far, he said.

Delhi municipalities have begun their use after a meeting of scientists and bureaucrats of NVBDCP, NIMR, ministry of health and family welfare and the Central Insecticide Board (CIB) authorised their application in January, sources said.

Dr NR Das, head of the department of Public Health in east MCD said, We have already procured diflubenzuron on NVBDCP directions and been using it for one month satisfactorily. However, we will be able to ascertain its degree of effectiveness only after two to three months.

For at least a decade, India has been the world’s largest producer of DDT, and the largest user, spraying more DDT than the rest of the world together. China and North Korea were the only two other nations making DDT at the end of the 20th century, but both cut off production. Counter to popular conceptions, India has struggled to control malaria, often being the only nation in the world to account increases in the disease from year to year, since 2001. Malaria increased despite increasing DDT application.

To fight malaria effectively DDT spraying should be limited to Indoor Residual Spraying (IRS), which leaves a fine coat of DDT on the walls of sleeping rooms, where malaria-carrying mosquitoes bite humans, then pause on the walls to squeeze water out of the blood they’ve fed on, to reduce weight to fly. Broadscale spraying of DDT only speeds development of resistance in all mosquito species, and many other pests.

India is catching up with the rest of the world on DDT.

Tip of the old scrub brush to India Today’s Twitter feed.

 

 


Mozambique uses 4 million mosquito nets in turn from pesticide, in war on malaria

June 20, 2017

Mozambique’s National Malaria Control Programme distributed 4 million LLIN, insecticide-impregnated nets, to protect children and others from malaria as they sleep, the time most malaria-infecting mosquito bites occur. Malaria Consortium photo

Mozambique’s National Malaria Control Programme distributed 4 million LLIN, insecticide-impregnated nets, to protect children and others from malaria as they sleep, the time most malaria-infecting mosquito bites occur. Malaria Consortium photo

Mozambique is one of only ten nations still using DDT for Indoor Residual Spraying (IRS) to fight malaria.

But DDT’s effectiveness diminishes rapidly, as does the effectiveness of the other eleven insecticides generally used for IRS against malaria or other vector-borne diseases. Insecticides are sprayed indoors, and not outdoors, to provide protection where humans are most often bitten, and to prevent non-target mosquitoes and other creatures from being exposed to the insecticides. This prevents harmful pests from developing resistance to the insecticides, and diminishes damage to beneficial species, like food fish.

Instead of spraying, malaria fighters turn increasingly to bednets impregnated with insecticide, known as Long-Lasting Insecticide-impregnated Nets (LLIN). A net provides closer to 100% protection from bites than IRS. A net immediately protects anyone sleeping under it, while IRS must treat at least 80% of nearby homes to achieve more than 50 percent prevention.

While still using IRS, Mozambique stakes its future malaria fighting on nets.

The Malaria Consortium aided in the recent distribution of nets.

Malaria Consortium has successfully completed a mass distribution campaign of over four million long-lasting insecticidal nets (LLINs) across Nampula and Niassa provinces in Mozambique. The nets were distributed almost simultaneously across all districts of each province – 23 districts in Nampula in November 2016, and 16 districts in Niassa in May 2017 – using a new operational model aimed at optimising resources.

Throughout the campaigns, Mozambique’s National Malaria Control Programme was responsible for the LLIN acquisition and led overall planning and implementation through the decentralised structures of the health system. Malaria Consortium’s role consisted of operational support, which included financial management, transport, procurement, logistics, training, management of service providers, efficient use of resources and effective coordination at provincial, district and field levels.

Sonia Gwesela, Malaria Consortium Mozambique Country Director said, “In Nampula Province, a major achievement was that 99 percent of households collected their nets. We successfully delivered 98 percent of the nets in both provinces, coming well above the 90 percent target set by the National Malaria Control Programme.

“With the successful completion of the distribution, we can now focus on a post-distribution communications campaign about the correct use of LLINs,” she concluded.

The Malaria Prevention and Control Project is funded by the Global Fund to Fight AIDS, TB and Malaria and supports the efforts of the Mozambican government to reduce malaria throughout the country through scale up of prevention and control efforts with community involvement. Malaria Consortium is working in partnership with World Vision, Fundacao para o Desenvolvimento da Comunidadeo, International Relief and Development, and the Mozambique Ministry of Health.

Bednets can be twice as effective as IRS in preventing the spread of malaria. Beating malaria also requires upgrading health care for quick diagnoses and quick, complete treatment of malaria in humans, and prevention projects to drain mosquito-breeding places within 50 yards of homes; more prevention of bites means less medical treatment is required.

WHO estimated 5 million people died of malaria in the 1950s into the 1960s. WHO’s Malaria Report 2016 reported malaria deaths fell to less than 430,000 world wide, a more than 90 percent reduction since 1963, mostly accomplished without DDT.

Malaria Consortium on Twitter, @FightingMalaria.

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Quick shot: What if it were your kid who had cancer? How would you pay?

June 11, 2017

Incredibly sad photo.

Cullen Crawford posted this on Twitter:

Cullen Crawford posted this on Twitter: “We dip our toes into depressing images on this site but nothing no approaches these torn up lotto ticket on floor of emergency room triage.”

If America is a just and true nation, the Affordable Care Act will be strengthened, not repealed to redistribute wealth to rich guys.

This is not a cartoon. It’s real life.


No, Rachel Carson didn’t cause an increase in malaria; bonus film to WGBH American Experience “Rachel Carson”

February 7, 2017

Rachel Carson at a microscope, American Experience/RetroReport image. Did Carson's work cause an increase in malaria? Is she to blame for continued malaria deaths? No, answers a short film bonus to "Rachel Carson," the 2017 PBS film.

Rachel Carson at a microscope, American Experience/RetroReport image. Did Carson’s work cause an increase in malaria? Is she to blame for continued malaria deaths? No, answers a short film bonus to “Rachel Carson,” the 2017 PBS film.

A straight up, historic look at the question of Rachel Carson’s fault in stopping malaria.

Anti-environmentalists and corporate hoaxsters argue that Rachel Carson should be blamed for an imaginary increase in malaria deaths, after the U.S. banned DDT use on crops.

In conjunction with WGBH’s American Experience film on Carson released early in 2017, this short film focusing on malaria as a continuing plague puts to rest the idea that Carson should be blamed at all.

Soaking in the bathtub, we find the film not strident enough in defense of Carson; but for those strident nuts who claim Carson a murderer, it may have some good effect. And of course, you, intelligent dear reader, will be persuaded more gently.

Where malaria is the question, DDT is not the answer. Where malaria still exists, it’s not Rachel Carson’s fault.

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Fact sheet for World Malaria Report 2016

December 16, 2016

A woman shows the mosquito net that protects her and her family from malaria transmission, in India. India remains the world's top DDT user, but is switching to nets in an effort to bring malaria rates down and set up malaria eradication before the end of DDT in 2020. WHO image.

A woman shows the mosquito net that protects her and her family from malaria transmission, in India. India remains the world’s top DDT user, but is switching to nets in an effort to bring malaria rates down and set up malaria eradication before the end of DDT in 2020. WHO image.

World Health Organization publishes an annual World Malaria Report, with the year appended to the title. It summarizes the state of the fight against malaria worldwide, recording progress and setbacks.

In the tally of progress we get a clear indication of what is needed to continue or increase that progress, with the ultimate goal of controlling malaria to the point it poses no great economic risk, or health risk, to any nation, or better that human malaria is eradicated.

World Malaria Report 2016 is 184 pages, shorter than some previous reports but packed with figures and history, some of which requires greater background to understand completely.

For example, the 2016 publication notes that about 412,000 people died from malaria in 2016. This is a shocking figure. Most of the news coverage of the report mentions this death toll in the first paragraph.

It’s too many deaths. But it’s a more than 50% reduction in deaths from 1990s rates, and it’s a more than 90% reduction from the annual death tolls that shocked the world to concerted action after World War II. Most estimates are that about 5 million people a year died from malaria through the 1950s, and into the 1960s.

WHO concentrates on the malaria fight, and plays down the political aspects to encourage international cooperation to help fight the disease. But there are political statements made, if one has the background to understand them. There remains controversy over the use of DDT, with many people yelling far and wide that if ‘bans on DDT were removed’ then malaria would quickly become an eradicated disease. This position ignores the facts, that there were still 5 million people dying each year during peak DDT use; that death tolls plunged after the U.S. banned DDT use on crops; that the U.S. ban covered only crop use, and that DDT use against disease has never been banned anywhere in the world; and that DDT use continued long after the U.S. banned DDT, around the world. DDT use never stopped.

Taken together, we would understand that the 90% reduction in malaria deaths from peak DDT use years, was accomplished mostly without DDT, and that therefore DDT is not a panacea.

World Malaria Report 2016 also tallies the slow demise of DDT. Mosquito resistance to pesticides, especially DDT, is a major problem in the fight against the disease. But more DDT can’t fix that problem now that every mosquito on Earth carries alleles that make them resistant and wholly immune to the stuff. DDT will probably never be a panacea, even were its manufacture not scheduled to stop very soon.

History, and a complete assessment of the science and current conditions in the frontlines of the malaria fight, can help us put these things in perspective.

So far, only the Los Angeles Times in the U.S. provided any in-depth reporting on World Malaria Report 2016. We hope other media will take up the challenge to inform. They will find WHO’s Fact Sheet useful.

With that warning in mind, it’s good to look at the broad outlines of the report, which WHO has packaged into a fact sheet for our convenience.

Fact Sheet: World Malaria Report 2016

13 December 2016

The World Malaria Report, published annually by WHO, tracks progress and trends in malaria control and elimination across the globe. It is developed by WHO in collaboration with ministries of health and a broad range of partners. The 2016 report draws on data from 91 countries and areas with ongoing malaria transmission.

Global progress and disease burden (2010–2015)

According to the report, there were 212 million new cases of malaria worldwide in 2015 (range 148–304 million). The WHO African Region accounted for most global cases of malaria (90%), followed by the South-East Asia Region (7%) and the Eastern Mediterranean Region (2%).

In 2015, there were an estimated 429 000 malaria deaths (range 235 000–639 000) worldwide. Most of these deaths occurred in the African Region (92%), followed by the South-East Asia Region (6%) and the Eastern Mediterranean Region (2%).

Between 2010 and 2015, malaria incidence rates (new malaria cases) fell by 21% globally and in the African Region. During this same period, malaria mortality rates fell by an estimated 29% globally and by 31% in the African Region.

Between 2010 and 2015, malaria incidence rates (new malaria cases) fell by 21% globally and in the African Region. During this same period, malaria mortality rates fell by an estimated 29% globally and by 31% in the African Region.

Other regions have achieved impressive reductions in their malaria burden. Since 2010, the malaria mortality rate declined by 58% in the Western Pacific Region, by 46% in the South-East Asia Region, by 37% in the Region of the Americas and by 6% in the Eastern Mediterranean Region. In 2015, the European Region was malaria-free: all 53 countries in the region reported at least 1 year of zero locally-acquired cases of malaria.

Children under 5 are particularly susceptible to malaria illness, infection and death. In 2015, malaria killed an estimated 303 000 under-fives globally, including 292 000 in the African Region. Between 2010 and 2015, the malaria mortality rate among children under 5 fell by an estimated 35%. Nevertheless, malaria remains a major killer of under-fives, claiming the life of 1 child every 2 minutes.

Trends in the scale-up of malaria interventions

Vector control is the main way to prevent and reduce malaria transmission. Two forms of vector control are effective in a wide range of circumstances: insecticide-treated mosquito nets (ITNs) and indoor residual spraying (IRS).

ITNs are the cornerstone of malaria prevention efforts, particularly in sub-Saharan Africa. Over the last 5 years, the use of treated nets in the region has increased significantly: in 2015, an estimated 53% of the population at risk slept under a treated net compared to 30% in 2010.

Indoor residual spraying of insecticides (IRS) is used by national malaria programmes in targeted areas. In 2015, 106 million people globally were protected by IRS, including 49 million people in Africa. The proportion of the population at risk of malaria protected by IRS declined from a peak of 5.7% globally in 2010 to 3.1% in 2015.

Diagnostics

WHO recommends diagnostic testing for all people with suspected malaria before treatment is administered. Rapid diagnostic testing (RDTs), introduced widely over the past decade, has made it easier to swiftly distinguish between malarial and non-malarial fevers, enabling timely and appropriate treatment.

New data presented in the report show that, in 2015, approximately half (51%) of children with a fever who sought care at a public health facility in 22 African countries received a malaria diagnostic test compared to 29% in 2010. Sales of RDTs reported by manufacturers rose from 88 million globally in 2010 to 320 million in 2013, but fell to 270 million in 2015.

Treatment

Artemisinin-based combination therapies (ACTs) are highly effective against P. falciparum, the most prevalent and lethal malaria parasite affecting humans. Globally, the number of ACT treatment courses procured from manufacturers increased from 187 million in 2010 to a peak of 393 million in 2013, but subsequently fell to 311 million in 2015.

Prevention in pregnancy

Malaria infection in pregnancy carries substantial risks for the mother, her fetus and the newborn child. In Africa, the proportion of women who receive intermittent preventive treatment in pregnancy (IPTp) for malaria has been increasing over time, but coverage levels remain below national targets.

IPTp is given to pregnant women at scheduled antenatal care visits after the first trimester. It can prevent maternal death, anaemia and low birth weight, a major cause of infant mortality. Between 2010 and 2015, there was a five-fold increase in the delivery of 3 or more doses of IPTp in 20 of the 36 countries that have adopted WHO’s IPTp policy – from 6% coverage in 2010 to 31% coverage in 2015.

Insecticide and drug resistance

In many countries, progress in malaria control is threatened by the rapid development and spread of antimalarial drug resistance. To date, parasite resistance to artemisinin – the core compound of the best available antimalarial medicines – has been detected in 5 countries of the Greater Mekong subregion.

Mosquito resistance to insecticides is another growing concern. Since 2010, 60 of the 73 countries that monitor insecticide resistance have reported mosquito resistance to at least 1 insecticide class used in nets and indoor spraying; of these, 50 reported resistance to 2 or more insecticide classes.

Progress towards global targets

To address remaining challenges, WHO has developed the Global Technical Strategy for Malaria 2016-2030 (GTS). The Strategy was adopted by the World Health Assembly in May 2015. It provides a technical framework for all endemic countries as they work towards malaria control and elimination.

This Strategy sets ambitious but attainable goals for 2030, with milestones along the way to track progress. The milestones for 2020 include:

  • Reducing malaria case incidence by at least 40%;
  • Reducing malaria mortality rates by at least 40%;
  • Eliminating malaria in at least 10 countries;
  • Preventing a resurgence of malaria in all countries that are malaria-free.

Progress towards the GTS country elimination milestone is on track: In 2015, 10 countries and areas reported fewer than 150 locally-acquired cases of malaria. A further 9 countries reported between 150 and 1000 cases.

However, progress towards other GTS targets must be accelerated. Less than half (40) of the 91 malaria-endemic countries are on track to meet the GTS milestone of a 40% reduction in malaria case incidence by 2020. Progress has been particularly slow in countries with a high malaria burden.

Forty-nine countries are on track to achieve the milestone of a 40% reduction in malaria mortality; this figure includes 10 countries that reported zero malaria deaths in 2015.

Funding trends

In 2015, malaria funding totalled US$ 2.9 billion, representing only 45% of the GTS funding milestone for 2020. Governments of malaria-endemic countries provided 32% of total funding. The United States of America and the United Kingdom are the largest international funders of malaria control and elimination programmes, contributing 35% and 16% of total funding, respectively. If the 2020 targets of the GTS are to be achieved, total funding must increase substantially.

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Why we need war on the mosquito, the deadliest animal – Bill Gates

October 16, 2016

World's Deadliest Animals, Gates Foundation

World’s Deadliest Animals, Gates Foundation

One could quibble, and point out that it’s the malaria parasite that does the dirty work, more than the mosquito; but it’s only a quibble.

Short film from Bill Gates explaining why he helps wage war on the lowly mosquito. Use of science to find ways to defeat mosquito-borne disease transmission is especially important in the post-DDT world, since DDT resistance now aids every mosquito on Earth.

GatesNotes said:

There are about a dozen different diseases that are spread to humans by mosquito bites including dengue, yellow fever, Zika, chikungunya, and malaria. This little mosquito actually kills more humans than any other thing.

Learn more at: http://b-gat.es/2cUd9Ff


How USA spends so much money to fight malaria in other nations

January 2, 2016

Fighting malaria is difficult, and complex, and expensive. No magic bullet can slow or stop malaria.

Reasonable people understand the stakes, not only for Africa, where $12 billion is lost every year to malaria illness and death, according to WHO records; but also for all nations who trade with Africa and other malaria endemic nations in the world.

What should we do about malaria?

Before we leap to solutions, let us look to see what the United States is already doing, according to USAID, the agency which has led U.S. malaria-fighting since the 1950s.

USAID explains on their website:

Fighting Malaria

A mother and child sit under the protection of malaria nets

A mother and child sit under the protection of malaria nets. Learn more about PMI’s contributions to the global fight against malaria. Maggie Hallahan Photography

Each year, malaria causes about 214 million cases and an estimated 438,000 deaths worldwide

While malaria mortality rates have dropped by 60 percent over the period 2000–2015, malaria remains a major cause of death among children. Although the disease is preventable and curable, it is estimated that a child dies every minute from malaria. In Asia and the Americas, malaria causes fewer severe illnesses and deaths, but antimalarial drug resistance is a serious and growing problem.

The U.S. Agency for International Development (USAID) has been committed to fighting malaria since the 1950s. Malaria prevention and control remains a major U.S. foreign assistance objective and supports the U.S. Government’s vision of ending preventable child and maternal deaths and ending extreme poverty. USAID works closely with national governments to build their capacity to prevent and treat the disease. USAID also invests in the discovery and development of new antimalarial drugs and malaria vaccines. USAID-supported malaria control activities are based on country-level assessments, and a combination of interventions are implemented to achieve the greatest public health impact – most importantly the reduction of maternal and child mortality. These interventions include:

  • Indoor residual spraying (IRS): IRS is the organized, timely spraying of an insecticide on the inside walls of houses or dwellings. It kills adult mosquitoes before they can transmit malaria parasites to another person.
  • Insecticide-treated mosquito nets (ITNs): An insecticide-treated mosquito net hung over sleeping areas protects those sleeping under it by repelling mosquitoes and killing those that land on it.
  • Intermittent preventive treatment for pregnant women (IPTp): Approximately 125 million pregnant women annually are at risk of contracting malaria. IPTp involves the administration of at least two doses of an antimalarial drug to a pregnant woman, which protects her against maternal anemia and reduces the likelihood of low birth weight and perinatal death.
  • Diagnosis and treatment with lifesaving drugs: Effective case management entails diagnostic testing for malaria to ensure that all patients with malaria are properly identified and receive a quality-assured artemisinin-based combination therapy (ACT).

The President’s Malaria Initiative (PMI) works in 19 focus countries in sub-Saharan Africa and the Greater Mekong Subregion in Asia. PMI is an interagency initiative led by USAID and implemented together with the U.S. Centers for Disease Control and Prevention. In 2015, PMI launched its next 6-year strategy for 2015–2020, which takes into account the progress over the past decade and the new challenges that have arisen. It is also in line with the goals articulated in the Roll Back Malaria (RBM) Partnership’s second generation global malaria action plan, Action and Investment to Defeat Malaria (AIM) 2016–2030: for a Malaria-Free World [PDF, 18.6MB] and The World Health Organization’s (WHO’s) updated Global Technical Strategy: 2016–2030 [PDF, 1.0MB]. The U.S. Government’s goal under the PMI Strategy 2015-2020 [PDF, 8.9MB] is to work with PMI-supported countries and partners to further reduce malaria deaths and substantially decrease malaria morbidity, toward the long-term goal of elimination. USAID also provides support to malaria control efforts in other countries in Africa, including Burkina Faso, Burundi and South Sudan, and one regional program in the Amazon Basin of South America. The latter program focuses primarily on identifying and containing antimalarial drug resistance.

Do you think the U.S. spends too much on foreign aid, even good aid to fight malaria? How much do you think is spent? Put your estimate in comments, please — and by all means, look for sources to see what the actual amount is.


Texas Gov. Abbott sides with cancer, brags about it

October 23, 2015

I get e-mail from Texas Gov. Greg Abbott, and all too often it leaves me shaking my head in disgust.

This one came today. I suppose one needs to understand that the e-mail is intended to mislead the recipients about what Gov. Abbott is doing.

In the War on Cancer, Abbott has sided with cancer. As Attorney General in the later stages of the wilting administration of the beleaguered Rick Perry, Abbott refused to investigate a Texas Constitutionally-established, billion-dollar fund to support cancer research whose administration then-Gov. Perry had turned over to old political friends.

Tens of millions of dollars of taxpayer money went into black holes of bank accounts of Perry’s political supporters.

Abbott should have recused himself from any investigation by his office, because under the laws setting up the research fund, he was on the board.  Any investigation would need to answer the question about what Abbott had done to be sure the funds were spent as the law intended.

Conflicts of interest don’t bother Greg Abbott, though, so long as the conflicts work in favor of his friends, and political donors.

Fortunately for Texas, there is another, separate office to investigate public wrongdoing in state agencies, the Public Integrity Unit of the Travis County District Attorney’s office. That office indicted one of the cancer agency’s officials (he was convicted of misappropriating $11 million in public funds), and promised to indict more.

This so angered Perry he stepped all over the Texas Constitution to bring down the Travis County DA — and that earned Perry his own indictment after an investigation by a GOP-led task force.  Oh, yeah, there were other shenanigans by Perry that he might have wanted to cover up; but the cancer research abuse already sent one Perry buddy to jail.

You get the idea. Cancer research is political in Texas, and probably not all that serious a concern to GOP elected officials. Cancer is something poor people get. Republicans have health insurance.

For years, Planned Parenthood clinics in Texas and the rest of the nation offered free cancer screenings and checkups to women who otherwise could not get them for lack of money. These services have nothing to do with abortion, but a lot to do with obstetrical and gynecological care poor women cannot get otherwise.

Well, now Greg Abbott has ordered funding for those health care services to stop.

Read Abbott’s fund-raising letter — yes, he wants me (and you) to donate to his unholy campaign against women’s health care — and pay particular attention to how he avoids any mention of what kinds of services this funding cut-off will kill. He wants you to think he’s fighting abortion.

Which might be oddly and rarely true, if his denial of cancer screenings enables cancer to kill a woman who might have later gotten an abortion, or destroy her ability to conceive at all.

See the letter, sent with the subject, “Another win against Planned Parenthood”:

___________________________________

Friend,

Abbott cuts funding for cancer fightAbbott cuts funding for cancer fight disclaimer_______________________________________

So there you have it. Greg Abbott wants you to send him money, because he’s stopped poor women in Texas from getting cancer screenings.

Because, abortion, liberty, guns, and probably, illegal immigrants.

And, because he can get away with it.

How stupid must a Texas politician be to think promoting cancer will help any of those problems? How conniving must one be to try to hoodwink Texans into sending him money, neglecting to mention it’s money to support cutting medical care to women who need it?

How stupid must Texas voters be, if they don’t see through this corrupt ruse?

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September 23, 1858: DON’T wash your hands!

September 23, 2015

Ignaz Semmelweiss

Dr. Ignaz Semmelweis

This is one of the classic stories of public health, an issue that most U.S. history and world history texts tend to ignore, to the detriment of the students and the classroom outcomes.

This is the story as retold by Christopher Cerf and Victor Navasky in The Experts Speak:

In the 1850s a Hungarian doctor and professor of obstetrics named Ignaz Semmelweis [pictured at left] ordered his interns at the Viennese Lying-in Hospital to wash their hands after performing autopsies and before examining new mothers. The death rate plummeted from 22 out of 200 to 2 out of 200, prompting the following reception from one of Europe’s most respected medical practitioners:

“It may be that it [Semmelweis’ procedure] does contain a few good principles, but its scrupulous application has presented such difficulties that it would be necessary, in Paris for instance, to place in quarantine the personnel of a hospital during the great part of a year, and that, moreover, to obtain results that remain entirely problematical.”

Dr. Charles Dubois (Parisian obstetrician), memo to the French Academy
September 23, 1858

Semmelweiss’ superiors shared Dubois’ opinion; when the Hungarian physician insisted on defending his theories, they forced him to resign his post on the faculty.

Gotta wonder what Dr. Dubois would make of the suits and sanitation procedures required today for health professionals who treat Ebola victims.

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Yes, this is mostly an encore post. Fighting ignorance requires patience.

Yes, this is mostly an encore post. Fighting ignorance requires patience.


India, world’s last DDT maker, heaviest user, plans to stop

August 29, 2015

DDT sprayed in a vegetable market in India. (Photo: rzadigi) Living on Earth image

DDT sprayed in a vegetable market in India. (Photo: rzadigi) Living on Earth image

Sometimes big news sneaks up on us, without press releases. We often miss it.

Quiet little Tweet from journalist I’d never heard of, who passed along news from an obscure journal:

As a journalist, this guy has a piece of a world-wide scoop.

India is probably the last nation on Earth producing DDT.  In the last decade other two nations making the stuff got out of the business — North Korea and China. For several years now India has been the largest manufacturer of DDT, and far and away the greatest user, spraying more DDT against malaria-carrying mosquitoes, sand flies, and agricultural and household pests than the rest of the world combined.

As if an omen, India’s malaria rates did not drop, but instead rose, even as malaria rates dropped or plunged in almost every other nation on Earth.

Under the 2001 Stockholm Convention on Persistent Organic Pollutants (POPs) signed by more than 150 nations (not including the U.S.), DDT was one of a dozen chemicals targeted to be phased out due to its extremely dangerous qualities, including long-term persistence in the environment and bioaccummulation, by which doses of the stuff increase up the food chain, delivering crippling and fatal doses to top predators.

A perfect substitute for DDT in fighting some disease-carrying insects (“vectors”) has never been developed. Health officials asked, and the Stockholm negotiators agreed to leave DDT legally available to fight disease. Annex B asked nations to tell the World Health Organization if it wanted to use DDT. Since 2001, as DDT effectiveness was increasingly compromised by resistance evolved in insects, fewer and fewer nations found it useful.

The site Mr. Nazakat linked to is up and down, and my security program occasionally says the site is untrustworthy. It’s obscure at best. Shouldn’t news of this type be in some of India’s biggest newspapers?

I found an article in the Deccan Herald, confirming the report, but again with some

India-United Nations pact to end DDT use by 2020

India-United Nations pact to end DDT use by 2020

New Delhi, August 26, 2015, DHNS:

It would be better to switch to another insecticide, says expert

India is the lone user of DDT, though only in the malaria control programme, while rest of the world got rid of the chemical that has a lasting adverse impact on the environment. DH file photo

India is the lone user of DDT, though only in the malaria control programme, while rest of the world got rid of the chemical that has a lasting adverse impact on the environment. DH file photo

India has launched a $53 million project to phase out DDT by 2020 and replace them with Neem-based bio-pesticides that are equally effective.

India is the lone user of DDT, though only in the malaria control programme, while rest of the world got rid of the chemical that has a lasting adverse impact on the environment.

India on Tuesday entered into a $53 million (Rs 350 crore) partnership with the United Nations Industrial Development Organisation (UNIDO), United Nations Environment Programme and the Global Environment Facility to replace DDT with safer, more effective and green alternatives.

“As per the plan, the National Botanical Research Organisation, Lucknow, tied up with a company to produce Neem-based alternatives for the malaria programme. The production will start in six months,” Shakti Dhua, the regional coordinator of UNIDO told Deccan Herald.

Till last year, the annual DDT requirement was about 6,000 tonnes that has now been cut down to 4,000 tonnes as the government decided to stop using it in the Kala-Azar control programme.

A recent study by an Indo-British team of medical researchers found that using DDT without any surveillance is counter-productive as a vector control strategy as sand flies not only thrive but are also becoming resistant to DDT.

“It would be better to switch to another insecticide, which is more likely to give better results than DDT,” said Janet Hemingway, a scientist at the Liverpool School of Tropical Medicine. While the Health Ministry wanted to bring in synthetic pyrethroids, the United Nation agencies supports the bio-pesticides because of their efficacy and long-lasting effects.

“The new initiative would help check the spread of malaria and other vector-borne diseases. These include botanical pesticides, including Neem-based compounds, and long-lasting insecticidal safety nets that will prevent mosquito bites while sleeping,” Dhua said.

Ending the production and use of DDT is a priority for India as it is a signatory to the Stockholm Convention on Persistent Organic Pollutants (POP) of 2002 that seeks to eliminate the use of these chemicals in industrial processes, drugs and pesticides. DDT is one of the POPs.

The clock is counting down the last years of DDT.  Good.

If events unroll as planned, DDT making will end by 2020, 81 years after it was discovered to kill bugs, 70 years after it was released for civilian years, 70 years after problems with its use was first reported by the U.S. Fish and Wildlife Service, 58 years after the publication of Rachel Carson’s Silent Spring, 50 years after European nations banned some uses, 48 years after the famous U.S. ban on agricultural use, 19 years after the POPs Treaty.

When will the news leak out?

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Malaria No More notes milestone: Malaria at all time low

August 20, 2015

"End Malaria Now" demonstration from Jolkona.org, Seattle

“End Malaria Now” demonstration from Jolkona.org, Seattle

Remarkable progress against malaria marks the 21st century — but there was even more progress between 1960 and 2000. This progress usually is not noted in screeds against the World Health Organization (WHO), or Rachel Carson, or “crazy environmentalists.”

Through the 1950s, WHO estimated malaria deaths worldwide at about 5 million people each year. In about a decade of WHO’s malaria eradication campaign in temperate zones, the toll is estimated to have dropped to about 4 million dead each year.  WHO suspended the eradication campaign in 1963 when it was discovered that mosquitoes in central Africa were already resistant and immune to DDT, which was the chief pesticide used for Indoor Residual Spraying to temporarily knock down local mosquito populations. WHO tried to find substitutes for DDT, but by 1969 formally ended the program and stopped asking for money for eradication.

The fight against malaria continued, however. In 1972 the U.S. flooded malaria-prone nations with DDT which had been intended for use on U.S. crops, after the U.S. prohibited DDT on U.S. crops. For a dozen years all U.S. DDT production got channeled into Africa and Asia to fight disease.  U.S. makers had gotten out of DDT production by 1985 as production shifted to other nations.

Despite DDT’s failure, progress was made in medical care and especially in education on how to prevent mosquito bites.  The death toll dropped toward 1 million annually until about 1990. In the late 1980s, the medicines used to cure humans from malaria parasites failed, as the parasites developed their own resistance to the drugs. Through the 1990s, malaria deaths remained constant, or even rose.

A flood of concern in the late 1990s produced a coalition of malaria fighters with funding through the United Nations and non-governmental organizations (NGOs) such as the Gates Foundation and Wellcome Trust. In 1999, most of these groups agreed to fight harder, using “integrated vector management,” a variety of methods calculated to prevent mosquitoes from developing resistance to new pesticides, and prevent the malaria parasites from developing resistance to pharmaceuticals.

Plus, in nations where houses often were leaky to mosquitoes, these agencies provided bednets to prevent bites of malaria-carriers at peak biting periods, when people slept. By 2008, deaths dropped below a million each year for the first time, and progress has continued.

Beating malaria is a top goal of the United Nations’ Millennium Development Goals (MDGs); Malaria No More reported on a recently-completed report on those goals, which noted the progress against malaria.

Here is the press release from Malaria No More.

Malaria Deaths Reach All Time Low, U.N. Secretary General’s Final MDG Report Shows

NEW YORK, NY – July 6, 2015 – Malaria deaths have reached an all-time low and 6.2 million lives have been saved from the disease between 2000-2015, according to a new United Nations report announced by U.N. Secretary-General Ban Ki-moon’s office today. The final report on progress of the Millennium Development Goals (MDGs), which are set to expire this year, highlights an historic 69 percent decline in the rate of child deaths from malaria in Africa.

The report provides an update to all eight MDG Goals. The unprecedented global leadership over the past ten years to combat malaria has not only surpassed the disease-specific MDG target (Goal 6, Combat HIV/AIDS, Malaria and Other Diseases), but those efforts also contributed to critical progress toward achieving Goals 4 (Reduce Child Mortality) and 5 (Improve Maternal Health).

“Malaria is one of the standout successes of the MDGs thanks to continuous innovation, bold endemic country leadership and steadfast donor commitment,” said Ray Chambers, the U.N. Secretary-General’s Special Envoy for Malaria and Financing the Health MDGs. “We need to build on this success to ensure no child, woman or man dies from a mosquito bite and that we ultimately eradicate this disease.”

Thanks to the leadership of the United States, the Global Fund to Fight AIDS, Tuberculosis and Malaria and other international donors, malaria financing has grown dramatically from 2000-2015 to more than $3 billion annually, and political leadership has fueled the delivery of more than 1 billion mosquito nets to Africa along with hundreds of millions of effective tests and treatments.

Although these results have successfully surpassed the MDG target, the fight against malaria is not finished. Malaria remains a major global health security challenge with an estimated 3.3 billion people at risk globally. Thanks to recent success in achieving real and measureable progress, coupled with steadfast political leadership and a promising pipeline of transformative new technologies, malaria-affected regions have set ambitious goals for elimination including transformative 2020 targets in Southern Africa, Southeast Asia and the Caribbean.

“Malaria is one of the oldest and deadliest diseases in human history,” said Martin Edlund, CEO of Malaria No More. “For the first time in history we have the opportunity to capitalize on our success and end malaria within a generation; we can’t afford to miss that opportunity.”

Click here to download the full report.

Chart from USNews.com:

Estimated change in malaria incidence rate (cases per 1,000 population at risk) and malaria mortality rate (deaths per 100,000 persons at risk), 2000-2015. USNews.com chart, based on MDG report.

Estimated change in malaria incidence rate (cases per 1,000 population at risk) and malaria mortality rate (deaths per 100,000 persons at risk), 2000-2015. USNews.com chart, based on MDG report.

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Malaria Twitterstorm, summer of 2015

August 18, 2015

Several good developments in the War on Malaria, worldwide — along with some alarming signs.  Maybe there will be time to blog seriously about each of these things later. Let’s get them known, and keep discussion going for the best way to beat malaria in a post-DDT world.

QPharm Tweeted about DSM 265, an experimental, one-dose treatment developed by the Medicines for Malaria Venture (MMV); the video is useful for the background those new to the issue can get on the problems of treating malaria, which make great hurdles for campaigns to eradicate malaria.

Here’s the video the Tweet leads to.

MMV said:

DSM265 is a selective inhibitor of the plasmodial enzyme called DHODH. DHODH is a key enzyme in the replication of the parasite. If we can inhibit that enzyme with DSM265, we can stop the life of the parasite.

Voice of America reported on Rollback Malaria’s call for $100 billion to be spent in the next 15 years, to stamp out the disease.

Malaria deaths are, in 2015, at an “all time low.” Deaths hover around 500,000 per year, most in Africa, and most among children under the age of 5. A staggering total, until compared to the post-World War II estimates of more than 5 million deaths per year, or the more than 3 million deaths per year in 1963, the year the World Health Organization (WHO) had to stop its ambitious campaign to eradicate malaria when pesticide DDT, upon which the campaign was based, produced resistance in mosquitoes in areas where the campaign had not yet reached.

Beating malaria is one of the Millennium Development Goals of the United Nations; this year’s report on MDG acknowledged the great progress already made.

Another non-governmental malaria-fighting organization discussed the news; see the press release from Malaria No More.

Medical News Today Tweeted out a tout for its own coverage of malaria — notable for a good, basic explanation of malaria and how to fight it.  I wish critics of Rachel Carson and WHO were familiar with half of these basic facts.

Medical News Now's Fast Facts on Malaria

Medical News Now’s Fast Facts on Malaria. Notable, that annual deaths now are way below the million mark. Good news!

One malaria vaccine has won approval for final testing. Good news, though anyone who follows vaccines knows it will take a while to test, and anyone who knows malaria fighting knows there are four different parasites, and delivery of any medical care is tough in far too many parts of the world where any form of malaria is endemic. Even small good news is good news.

Are we better informed about malaria now? Do we understand spreading a lot more DDT is not the answer?

 


Wellcome Trust interactive on malaria parasites’ lifecycle

August 12, 2015

Screen capture of the Wellcome Trust HTML presentation on the life cycle of malaria parasites. Malaria fighters know all this almost instinctively; too often policy makers fail to understand it, and so they recommend policies that do not make medical or economic sense in fighting the disease. Click image to go to Wellcome Trust site for full presentation.

Screen capture of the Wellcome Trust HTML presentation on the life cycle of malaria parasites. Malaria fighters know all this almost instinctively; too often policy makers fail to understand it, and so they recommend policies that do not make medical or economic sense in fighting the disease. Click image to go to Wellcome Trust site for full presentation.

Britain’s Wellcome Trust takes as one of its key missions the fight against malaria.  The Trust is a charitable foundation created from profits of pharmaceutical development and sales.

Recently I found this HTML animation presentation on the life cycle of the malaria parasite, something all malaria fighters must know to be effective.

It’s also something that DDT advocates seem unable to comprehend.  Malaria is not a virus, nor is it a venom mosquitoes manufacture, but it is a parasite that infects (and disables) both mosquitoes and humans. Mosquitoes catch the parasite from an infected human host. After the malaria parasite completes a couple of cycles in the gut of the mosquito, the parasite can be transmitted back to humans by a mosquito bite. And the cycle continues.

Since complete eradication of malaria-carrying mosquitoes is practically impossible in almost all cases, beating malaria requires an interruption in the cycle of transmission of the parasite, plus the curing of the disease in infected human hosts.

For example, the old World Health Organization (WHO) malaria eradication campaign, which operated from 1955 to 1963, DDT was used to temporarily knock down a population of mosquitoes, with hopes human hosts would be ridded of malaria parasites so that, in six months or so, when the mosquito populations roared back, there would be no malaria in local humans to infect mosquitoes. Consequently, mosquitoes can’t transmit a parasite they don’t have.

Lost on far too many people: Humans must be cured of malaria to prevent transmission. Beating malaria takes a lot more than just killing mosquitoes.

Check out the interactive:  Malaria parasite life cycle

While you’re there, snoop around to see what else Wellcome Trust is up to in the malaria fight.

 


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