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Lessons for sub-Saharan Africa from a Malaria-free Belize

It can indeed be done: malaria can be eliminated. Countries are declared malaria-free by the World Health Organisation (WHO) after reporting zero indigenous cases for three consecutive years at least.

A malaria patient

On June 21, 2023, Belize, a small tropical Central American country, was declared malaria-free by the WHO, becoming the 43rd country to achieve that status since 1955.

In Africa, only three countries have achieved a similar outcome: Mauritius in 1973; La Réunion in 1979; and Algeria in 2019.

Sadly, there continues to be an increase in malaria cases across the world, with 247 million cases of malaria having been recorded in 2021 compared to 245 million cases in 2020, according to the World Malaria Report 2022.

According to the report, Africa was home to about 95 per cent of all malaria cases and 96 per cent of deaths in 2021. Children under five years of age accounted for about 80 percent of all malaria deaths in the continent.

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The high prevalence rate remains despite the concerted efforts to end malaria across the continent.

Among the notable ongoing efforts is the Southern African Development Community (SADC) Elimination 8 (SADC E8) Initiative which is a coalition of eight countries (Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe) working to eliminate malaria in Southern Africa by 2030.

With Belize’s success, sub-Saharan African (SSA) countries can draw some lessons to accelerate their own quest to eliminate malaria.

The first lesson that can be gleaned from Belize’s experience is to undertake enhanced surveillance, especially among high-risk populations.

Belize had strong collaboration with the agricultural and tourism sectors that supported proactive surveillance among high-risk groups such as migrant workers from malaria endemic areas.

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It is notable that Belize maintained malaria surveillance efforts throughout the COVID-19 pandemic, particularly on the borders with Mexico and Guatemala. One such high-risk population that SSA countries can focus on is pregnant women.

According to a study published in The Lancet in 2019, the probability of malaria detection in malaria-endemic areas, is higher among pregnant women in antenatal care than among the non-pregnant population.

Secondly, the need to maintain a malaria workforce to deliver prevention interventions and training of clinicians on malaria diagnosis and treatment is evident from the experience in Belize.

The Pan-American Health Organisation identified Belize’s malaria program’s retention of dedicated vector control staff to guide the technical aspects of malaria control interventions and monitor their implementation as a key success factor in making Belize malaria-free.

Governments across the SSA region may need to take a leaf out of Belize’s book by investing more resources in recruiting dedicated personnel whose focus will be on prevention of malaria.

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Thirdly, Belize’s vector control staff established good relationships with the main farms that hire workers from neighbouring malaria-endemic countries, ensuring the distribution of information, education, and communication materials, as well as malaria testing, prompt diagnosis, and treatment.

Regional partnerships across the SSA region, as evidenced by the SADC E8 Initiative, should be encouraged to bolster ongoing individual state-led efforts to end malaria.

Belize also developed a plan to prevent the re-establishment of malaria transmission by maximizing access to diagnosis and treatment through health facilities as well as the use of community health workers and voluntary collaborators in nearly every locality.

The community health worker approach can be particularly helpful in the SSA region as it would improve access to treatment for high-risk segments of the population such as pregnant women, in areas where access to healthcare is hindered by long distances to healthcare facilities.

Effective medicines are also critical to the control and elimination of malaria. However, the emergence of partial resistance to artemisinin-based combinations therapies (ACT), which has been confirmed in Eritrea, Rwanda, and Uganda, is threatening to derail global efforts to end malaria.

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But on a positive note, this has inspired research to develop new tools to meet the remaining unmet needs in malaria.

As a case in point, Novartis is working with Medicines for Malaria Venture (MMV) to develop more effective antimalarial treatments, including a new optimized dose strength of its ACT to address the need for treatment for malaria in infants weighing less than five kilograms – for whom there is no approved treatment.

Considering the heavy malaria burden borne by SSA, the Belize success story is an inspiration and a reminder that ending malaria is possible.

The lessons leading up to Belize’s feat will be invaluable for governments and agencies working toward a malaria-free world, a pursuit for which the SSA region is evidently the last frontier.

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