tag:theconversation.com,2011:/uk/topics/malaria-762/articlesMalaria – The Conversation2024-03-27T16:13:22Ztag:theconversation.com,2011:article/2226222024-03-27T16:13:22Z2024-03-27T16:13:22ZNew TB skin test could offer cheaper and easier way to detect the disease<p>Detecting tuberculosis early could play a significant role in eradicating the world’s most deadly infectious disease. The World Health Organization says <a href="https://www.who.int/health-topics/tuberculosis#tab=tab_1">1.5 million people</a> die from this devastating disease each year. </p>
<p>People infected with <em>Mycobacterium tuberculosis</em>, the TB bacteria that attack the lungs, often do not know that they have it until their symptoms become severe. <a href="https://lunginstitute.co.za/2020/01/20/community-based-intervention-to-identify-undiagnosed-tb-cases/">Two out of every five cases</a> of TB remain undiagnosed or hidden.</p>
<p>One of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593585/">dangers</a> of this is unknowingly infecting others.</p>
<p><a href="https://www.mayoclinic.org/diseases-conditions/tuberculosis/diagnosis-treatment/drc-20351256">Current diagnostic methods</a> are <a href="https://www.nature.com/articles/d41586-024-00087-8">slow, often expensive, sometimes difficult to administer</a> and not easily accessible in the low-income regions where TB is most prevalent. </p>
<p>The oldest test, the <a href="https://www.healthline.com/health/sputum-stain-for-mycobacteria">sputum smear</a>, has been used for 100 years to detect TB. It is outdated, clumsy and can take three days to process. </p>
<p><a href="https://www.nhls.ac.za/priority-programmes/tb-genexpert/">GeneXpert</a> technology, the current gold standard for TB diagnosis, can detect the disease in an hour but is expensive and not available in remote areas.</p>
<p>Improvements in screening and diagnosis could help eradicate this curable disease. </p>
<p>One of the new routes to better diagnosis may be through detecting TB on the skin.</p>
<h2>Diagnosing a sickness</h2>
<p>Diseases have tell-tale chemical signatures. </p>
<p>Some cancers, for example, produce <a href="https://www.medicalnewstoday.com/articles/323620#:%7E:text=be%20most%20effective.-,Summary,%2C%20bodily%20fluids%2C%20or%20breath">signs</a> which dogs, with a sense of smell anywhere from <a href="https://www.uaf.edu/news/a-nose-1000-times-better-than-ours.php#:%7E:text=Lurking%20behind%20those%20textured%2C%20damp,thousand%20times%20better%20than%20humans.">1,000</a> to 10,000 times better than that of humans, can be trained to detect. </p>
<p>Our team at the University of Pretoria looked at whether a silicone rubber sampler could help us identify the <a href="https://www.sciencedirect.com/science/article/pii/S1570023223003471">chemical signatures of TB</a>.</p>
<p>We developed a patch, similar to a plaster (adhesive bandage), that could detect some of the chemicals from the TB bacteria. </p>
<p>We found we were able to distinguish between TB-positive and TB-negative individuals. </p>
<p>Our research holds promise for an inexpensive test that could be easy to transport and simple enough so that it would not need a healthcare worker to administer. </p>
<h2>It all started with the mosquito</h2>
<p>In 2021 we looked into why <a href="https://theconversation.com/were-a-step-closer-to-figuring-out-why-mosquitoes-bite-some-people-and-not-others-160038">mosquitoes bite some people and not others</a>. </p>
<p>We investigated whether there was a chemical difference to the skin surface between individuals who perceived themselves as being attractive to mosquitoes and those who were not. </p>
<p>Using a silicone rubber sampler, we were able to test the skin surface of 20 individuals. These samplers were specially developed and could be worn as a bracelet or an anklet.</p>
<p>We found chemical differences between the volunteers who were attractive to mosquitoes and those who were not.</p>
<h2>Turning to the TB test</h2>
<p>We built on the mosquito test to develop our research into TB detection. Could the deadly respiratory disease be diagnosed by attaching a plaster to a patient’s skin?</p>
<p>Skin patches, similar to a plaster, equipped with small silicone rubber bands were attached to the wrists of 15 TB-positive individuals at the Steve Biko Academic Hospital and the Tshwane District Hospital in Pretoria. Likewise, the rubber bands were attached to 23 TB-negative individuals at the University of Pretoria. </p>
<p>The silicone rubber bands served as effective traps for semi-volatile and <a href="https://pubmed.ncbi.nlm.nih.gov/18449462/#:%7E:text=Skin%20produces%20volatile%20organic%20compounds,pathways%20have%20a%20volatile%20potential.">volatile organic compounds</a> emitted by the body during the sampling period. </p>
<p>The bands were comfortable and non-restrictive and were worn for between 30 and 60 minutes. During this sampling period participants were free to go about their routines.</p>
<p>The bands were easily removed and sent to the laboratory.</p>
<p>In the laboratory we were able to separate the large number of chemical compounds found in the silicone rubber and were able to detect 27 compounds associated with TB. </p>
<h2>Promise of easy, inexpensive results</h2>
<p>As we refine and expand our findings, the human skin test for TB holds promise as a non-invasive screening tool in the fight against this infectious disease. </p>
<p>Our findings showed that:</p>
<ul>
<li><p>it is feasible to detect TB through skin emanations </p></li>
<li><p>the small and lightweight rubber band sample would be particularly suitable for use in rural and remote regions </p></li>
<li><p>individuals would not have to travel to a clinic or a hospital for testing as the patches could be applied at schools, households and gatherings </p></li>
<li><p>no special arrangements would be needed to transport the bands.</p></li>
</ul>
<p>This exciting breakthrough is not restricted to TB, but can also be repurposed to help detect other diseases such as malaria.</p>
<p><em>*Portia Makhubela and Egmont Rohwer co-authored the <a href="https://www.sciencedirect.com/science/article/pii/S1570023223003471">research</a> on which this article was based.</em></p>
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Read more:
<a href="https://theconversation.com/medical-science-has-made-great-strides-in-fighting-tb-but-reducing-poverty-is-the-best-way-to-end-this-disease-226136">Medical science has made great strides in fighting TB, but reducing poverty is the best way to end this disease</a>
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<p class="fine-print"><em><span>Yvette Naudé does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Two out of five cases of TB remain undiagnosed. A test using a skin patch could help change that.Yvette Naudé, Manager and NRF-rated researcher: Chromatography Mass Spectrometry - University of Pretoria and UP Institute for Sustainable Malaria Control (UP-ISMC), University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2239702024-03-14T19:24:37Z2024-03-14T19:24:37ZFrom malaria, to smallpox, to polio – here’s how we know life in ancient Egypt was ravaged by disease<figure><img src="https://images.theconversation.com/files/581183/original/file-20240312-29-m4tny7.jpg?ixlib=rb-1.1.0&rect=55%2C30%2C3338%2C2234&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The mention of ancient Egypt usually conjures images of colossal pyramids and precious, golden tombs. </p>
<p>But as with most civilisations, the invisible world of infectious disease underpinned life and death along the Nile. In fact, fear of disease was so pervasive it influenced social and religious customs. It even featured in the statues, monuments and graves of the Kingdom of the Pharaohs. </p>
<p>By studying ancient specimens and artefacts, scientists are uncovering how disease rocked this ancient culture. </p>
<h2>Tutankhamun’s malaria, and other examples</h2>
<p>The most direct evidence of epidemics in ancient Egypt comes from skeletal and DNA evidence obtained from the mummies themselves.</p>
<p>For instance, DNA recovered from the mummy of the boy pharaoh Tutankhamun (1332–1323 BC) led to the discovery he <a href="https://pubmed.ncbi.nlm.nih.gov/20159872/">suffered from malaria</a>, along with several other New Kingdom mummies (circa 1800 BC). </p>
<p>In other examples:</p>
<ul>
<li>skeletal and DNA <a href="https://pubmed.ncbi.nlm.nih.gov/11289521/">evidence found</a> in the city of Abydos suggests one in four people may have had tuberculosis </li>
<li>the mummy of Ramesses V (circa 1149–1145 BC) has scars indicating smallpox </li>
<li>the wives of Mentuhotep II (circa 2000 BC) were buried hastily in a “mass grave”, suggesting <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9186437/">a pandemic</a> had occurred</li>
<li>and the mummies of two pharaohs, Siptah (1197–1191 BC) and Khnum-Nekht (circa 1800 BC), were <a href="https://link.springer.com/article/10.1007/s10072-016-2720-9">found with</a> the deformed <a href="https://www.shorelineortho.com/specialties/foot_ankle_equinus.php">equinus</a> foot which is characteristic of the viral disease polio.</li>
</ul>
<h2>Signs of a disease-ravaged people</h2>
<p>Amenhotep III was the ninth pharaoh of the 18th dynasty, and ruled from about 1388–1351 BC.</p>
<p>There are several reasons experts think his reign was marked by a devastating disease outbreak. For instance, two separate carvings from this time depict a priest and a royal couple with the polio dropped-foot. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=844&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=844&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=844&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1060&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1060&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577699/original/file-20240224-30-9gt04r.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1060&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This 18th dynasty panel depicts a polio sufferer.</span>
<span class="attribution"><a class="source" href="https://en.m.wikipedia.org/wiki/File:Polio_Egyptian_Stele.jpg">Wikimedia</a></span>
</figcaption>
</figure>
<p>Statues of the lion-headed goddess of disease and health, Sekhmet, also <a href="https://pubmed.ncbi.nlm.nih.gov/33227516/">increased significantly</a>, suggesting a reliance on divine protection.</p>
<p>Another sign of a potential major disease outbreak comes in the form of what may be an early case of quarantine, wherein Amenhotep III moved his palace to the more isolated site of Malqata. This is further supported by the burning of a workers’ cemetery near Thebes. </p>
<p>Grave goods also became less extravagant and tombs less complex during this period, which suggests more burials were needed in a shorter time frame. These burials can’t be explained by war since this was an unusually peaceful period.</p>
<h2>Did disease trigger early monotheism?</h2>
<p>Amenohotep’s son – “the heretic King” Akhenaten (who was also Tutankhamun’s father) – abandoned the old gods of Egypt. In one of the earliest cases of monotheism, Akhenaten made worship of the Sun the official state religion. </p>
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<img alt="" src="https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=755&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=755&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=755&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=949&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=949&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577700/original/file-20240224-26-gurcmn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=949&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This panel (circa 1372-1355 BC) shows Akhenaten, Nefertiti and their daughters adoring the Sun god Aten.</span>
<span class="attribution"><a class="source" href="https://en.m.wikipedia.org/wiki/File:La_salle_dAkhenaton_(1356-1340_av_J.C.)_(Mus%C3%A9e_du_Caire)_(2076972086).jpg">Wikimedia</a></span>
</figcaption>
</figure>
<p>Some <a href="https://www.thecollector.com/akhenaten-monotheism-plague-egypt/">researchers think</a> Akhenaten’s dramatic loss of faith may have been due to the devastating disease he witnessed during his childhood and into his reign, with several of his children and wives having died from disease. But we’ve yet to find clear evidence for the role of disease in shaping his theology.</p>
<p>There’s also no direct DNA evidence of an outbreak under his father, Amenhotep III. There are only descriptions of one <a href="https://www.nationalgeographic.co.uk/history-and-civilisation/2021/01/these-pharaohs-private-letters-expose-how-politics-worked-3300-years-ago">in letters</a> Amenhotep III and Akhenaten exchanged with the Babylonians. </p>
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<figcaption>
<span class="caption">These clay tablets (circa 14th century BC), inscribed in Babylonian cuneiform, were sent to Amenhotep III or Akhenaten from the ruler Abdi-tirshi of Hazor (modern-day Israel).</span>
<span class="attribution"><span class="source">British Museum</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
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<p>To confirm an outbreak under Amenhotep III, we’d need to first recover pathogen DNA in human remains from this time, has been found in other Egyptian burial sites and for <a href="https://pubmed.ncbi.nlm.nih.gov/21993626/">other pandemics</a>.</p>
<p>Also, while many ancient epidemics are referred to as “plagues”, we can’t confirm whether any outbreaks in ancient Egypt were indeed caused by <em>Yersinia pestis</em>, the bacteria responsible for bubonic plague pandemics <a href="https://www.britannica.com/event/Black-Death">such as the Black Death</a> in Europe (1347-1351). </p>
<p>That said, researchers <a href="https://www.jstor.org/stable/3554655">have confirmed</a> the Nile rat, which was widespread during the time of the Pharaohs, would have been able to carry the <em>Yersinia</em> infection.</p>
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<a href="https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579796/original/file-20240305-24-p439xf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This 1811 etching depicts the ancient Plague of Athens (circa 430 BC), which may have been caused by <em>Yersinia</em> or a disease with similar symptoms such as smallpox, typhus or measles.</span>
<span class="attribution"><a class="source" href="https://www.britishmuseum.org/collection/image/1047063001">The British Museum</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<h2>How were outbreaks managed?</h2>
<p>Much like modern pandemics, factors such as population growth, sanitation, population density and mobilisation for war would have influenced the spread of disease in ancient Egypt. </p>
<p>In the case of war, it’s thought the Hittite army was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9186437/">weakened by</a> disease spread when it was famously <a href="https://www.khanacademy.org/humanities/world-history/world-history-beginnings/ancient-egypt-hittites/a/the-hittites">defeated by</a> Egyptian Pharaoh Ramses the Great in the battle of Kadesh (1274 BC). </p>
<p>In some ways, Egyptian medicine was advanced for its time. While these outbreaks occurred long before the development of antibiotics or vaccines, there is some evidence of public health measures such as the burning of towns and quarantining people. This suggests a basic understanding of how disease spreads. </p>
<p>Diseases caused by microorganisms would have been viewed as supernatural, or as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121911/">corruption of the air</a>. This is similar to other explanations held in different parts of the world, before germ theory was popularised in the 19th century.</p>
<h2>New world, old problems</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=750&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=750&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=750&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=943&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=943&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579797/original/file-20240305-28-cqzgoc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=943&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The funerary mask of Tutankhamun, who died as a teenager.</span>
<span class="attribution"><a class="source" href="https://en.m.wikipedia.org/wiki/File:CairoEgMuseumTaaMaskMostlyPhotographed.jpg">Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Many of the most widespread diseases that afflicted the ancient world are still with us.</p>
<p>Along with Tutankhamun, it’s thought <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30261-X/abstract">up to 70%</a> of the Egyptian population was infected with malaria caused by the <em>Plasmodium falciparum</em> parasite – spread by swarms of mosquitoes occupying the stagnant pools of the Nile delta. </p>
<p>Today, malaria affects about 250 million people, mostly in developing nations. Tuberculosis kills more than a million people each year. And smallpox and polio have only recently been eradicated or controlled through vaccination programs.</p>
<p>More work is yet to be done to detect individual pathogens in Egyptian mummies. This knowledge could shed light on how, throughout history, people much like us have grappled with these unseen organisms.</p>
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Read more:
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<p class="fine-print"><em><span>Thomas Jeffries does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Beyond the tombs and riches, life in ancient Egypt wasn’t so luxurious, after all.Thomas Jeffries, Senior Lecturer in Microbiology, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2220642024-02-02T10:37:41Z2024-02-02T10:37:41ZCape Verde is the third African country to eliminate malaria: here’s how<p>Cape Verde has been certified <a href="https://www.who.int/news/item/12-01-2024-who-certifies-cabo-verde-as-malaria-free--marking-a-historic-milestone-in-the-fight-against-malaria">malaria-free</a> by the World Health Organization. </p>
<p>The archipelago to the west of Senegal consists of 10 islands, and has a population of over <a href="https://datacommons.org/place/country/CPV?utm_medium=explore&mprop=count&popt=Person&hl=en">500,000 people</a>. It is the <a href="https://www.who.int/news/item/12-01-2024-who-certifies-cabo-verde-as-malaria-free--marking-a-historic-milestone-in-the-fight-against-malaria">third</a> country in Africa to be declared malaria-free, after Mauritius (in 1973) and Algeria (in 2019). </p>
<p>This brings the total of <a href="https://www.who.int/teams/global-malaria-programme/elimination/countries-and-territories-certified-malaria-free-by-who">malaria-free countries</a> to 43 worldwide. </p>
<p>Achieving malaria-free certification is no simple feat. As specialists in malaria prevention and control, we explain Cape Verde’s long journey to eliminating the disease that killed over 600,000 people worldwide in <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">2022</a>. </p>
<h2>How Cape Verde achieved its goal</h2>
<p>Malaria, endemic since settlement of the previously uninhabited islands in the <a href="https://www.cia.gov/the-world-factbook/countries/cabo-verde/">15th century</a>, affected all 10 islands before 1950. </p>
<p>During the <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-020-03455-7">1940s</a>, malaria posed a serious health threat. Severe epidemics resulted in over 10,000 cases and 200 deaths annually until targeted interventions were implemented.</p>
<p>The country was close to eliminating malaria <a href="https://www.africanconstituency.org/cape-verde-rising-to-the-challenge-of-malaria-eradication-by-2030/">twice</a> but these gains were not sustained. </p>
<p>Indoor residual spraying with <a href="https://mesamalaria.org/resource/eliminating-malaria-case-study-2-moving-towards-sustainable-elimination-cape-verde/">DDT</a> was done on each island until transmission ended nationwide in 1967. The residual effect of the insecticide helped kill mosquitoes over a longer period. Larviciding, the use of chemicals to target mosquito larvae at breeding sites, and active case detection were also undertaken.</p>
<p>The indoor residual spraying campaigns were stopped in 1969. The result was a <a href="https://mesamalaria.org/resource/eliminating-malaria-case-study-2-moving-towards-sustainable-elimination-cape-verde/">recurrence</a> of local transmission on Santiago island in 1973, followed by a large epidemic in 1977. </p>
<p>The second attempt to eliminate malaria started in 1978, and resulted in transmission interruption in 1983. Case numbers were maintained at <a href="https://mesamalaria.org/resource/eliminating-malaria-case-study-2-moving-towards-sustainable-elimination-cape-verde/">low levels from 1989</a>, confining malaria to Santiago and Boa Vista islands. But by <a href="https://mesamalaria.org/resource/eliminating-malaria-case-study-2-moving-towards-sustainable-elimination-cape-verde/">2006</a>, rising cases threatened tourism.</p>
<p>A political decision was made to boost nationwide elimination efforts. This led to a change in the country’s national health policy <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-018-2376-4#:%7E:text=From%20January%202010%20to%20December%202016%2C%2041%25%20(129%2F,5).&text=The%20island%20of%20Santiago%20has%20the%20highest%20number%20of%20cases">in 2007</a>. </p>
<p>The focus was on expanded diagnosis, early and effective treatment, and management of all cases.</p>
<p>Cape Verde was on track to eliminate malaria, but in 2017 recorded its “<a href="https://reliefweb.int/report/cabo-verde/cape-verde-hit-worst-malaria-outbreak-decades">worst malaria outbreak</a>” since 1991 with <a href="https://targetmalaria.org/latest/news/introducing-target-malaria-cabo-verde/">423 cases</a>. </p>
<p>The outbreak prompted a strategy adjustment. A <a href="https://targetmalaria.org/latest/news/introducing-target-malaria-cabo-verde">refocusing</a> on vector control, targeting affected neighbourhoods and malaria infection-prone communities, prevented increases in cases. Transmission was successfully interrupted for four years. </p>
<h2>Process to get certified malaria free</h2>
<p>The WHO reported 249 million malaria cases and 619,000 malaria-related deaths globally <a href="https://cdn.who.int/media/docs/default-source/malaria/world-malaria-reports/world-malaria-report-2023-spreadview.pdf?sfvrsn=bb24c9f0_4">in 2022</a>. </p>
<p>The African region accounted for 94% of all cases and 96% of all deaths. </p>
<p>Achieving malaria-free status highlights a nation’s determination and commitment. Countries must meet the WHO’s stringent criteria to reach this goal. Firstly, there must be <a href="https://www.who.int/teams/global-malaria-programme/elimination/certification-process#:%7E:text=WHO%20grants%20this%20certification%20when,that%20can%20prevent%20re%2Destablishment">zero indigenous</a> (locally) transmitted cases of malaria for at least three consecutive years. </p>
<p>Secondly a country must show that it has the ability to prevent reintroduction of disease transmission. </p>
<p>Only then may countries <a href="https://www.who.int/teams/global-malaria-programme/elimination/certification-process">request certification</a> from the WHO, working with regional offices to develop a certification plan and timeline. </p>
<p>If a country fails, it can reapply after three years. </p>
<p>To maintain malaria-free status, countries must continue to prevent transmission and submit annual reports to the WHO. </p>
<h2>Predictions for the next countries to take the leap</h2>
<p>The WHO’s <a href="https://cdn.who.int/media/docs/default-source/malaria/world-malaria-reports/world-malaria-report-2023-spreadview.pdf?sfvrsn=bb24c9f0_4">E-2025 initiative</a> focuses on 25 countries targeting elimination by 2025.</p>
<p>Belize achieved elimination in 2023. Malaysia reported zero local transmission for the fifth consecutive year, while Timor-Leste and Saudi Arabia achieved two consecutive years without local transmission (2021 and 2022). If maintained, they may be declared malaria-free soon. For the first time, both Bhutan and Suriname reported zero indigenous cases in 2022. </p>
<p>In the Africa region, several countries reported <a href="https://cdn.who.int/media/docs/default-source/malaria/world-malaria-reports/world-malaria-report-2023-spreadview.pdf?sfvrsn=bb24c9f0_4">significant reductions</a> in indigenous transmission in 2022. These included Botswana (43.5%), Eswatini (57.6%) and South Africa (31.3%). The Comoros saw a doubling in cases in the same year. São Tomé and Principe noted a 46% increase. </p>
<p>Despite <a href="https://cdn.who.int/media/docs/default-source/malaria/world-malaria-reports/world-malaria-report-2023-spreadview.pdf?sfvrsn=bb24c9f0_4">country efforts</a>, extreme climate events and cross-border movement may have an impact on transmission or recurrence. </p>
<p>Attaining certification holds importance, and Cape Verde’s success will drive positive development in the country. </p>
<p><a href="https://www.trade.gov/country-commercial-guides/cabo-verde-tourism#:%7E:text=Tourism%20is%20a%20primary%20driver,Cabo%20Verde's%20foreign%20direct%20investment.">Tourism</a> plays an important role in the country’s economy. It accounted for a substantial share of the country’s GDP pre-COVID (24%), formal employment (10%), and the majority of foreign investment. Malaria-free status can potentially draw more visitors to the country.</p>
<p>The infrastructure established for malaria elimination has bolstered the country’s health system. This can be beneficial against other mosquito-borne diseases such as <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON498">dengue fever</a>, which also affects tourism. </p>
<p>A country’s “personal” milestone can help drive global malaria elimination efforts. Cape Verde’s achievement is a call to action for the malaria community to not give up. We must push harder to end malaria for good.</p><img src="https://counter.theconversation.com/content/222064/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Malaria in Africa accounts for 96% of deaths worldwide. Cape Verde became only the third country in Africa to be declared malaria free this year. This is how they did it.Tiaan de Jager, Dean: Faculty of Health Sciences and Director: UP Institute for Sustainable Malaria Control, University of PretoriaTaneshka Kruger, UP ISMC: Project Manager and Coordinator, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2171462023-11-21T13:09:29Z2023-11-21T13:09:29ZMalaria: two groundbreaking vaccines have been developed, but access and rollout are still big stumbling blocks<p><em>The approval of two malaria vaccines – the RTS,S/AS01 vaccine in 2021 and the R21/Matrix-MTM vaccine in 2023 – will help control, and eventually help eradicate, a disease that causes more than <a href="https://www.who.int/news-room/fact-sheets/detail/malaria#:%7E:text=Disease%20burden&text=cases%20in%202020.-,The%20estimated%20number%20of%20malaria%20deaths%20stood%20at%20619%20000,63%20000%20more%20malaria%20deaths.">600,000 deaths</a> annually.</em></p>
<p><em>Nearly <a href="https://www.who.int/initiatives/malaria-vaccine-implementation-programme#:%7E:text=The%20first%20malaria%20vaccine%2C%20RTS,Programme%2C%20MVIP%2C%20since%202019.">2 million children</a> in Ghana, Kenya and Malawi have been vaccinated with the <a href="https://www.who.int/initiatives/malaria-vaccine-implementation-programme">RTS,S/AS01</a> vaccine. It will be rolled out to more African countries from early next year.</em></p>
<p><em>The second vaccine, <a href="https://www.ox.ac.uk/news/2023-10-02-oxford-r21matrix-m-malaria-vaccine-receives-who-recommendation-use-paving-way-global">R21/Matrix-MTM</a>, approved by the World Health Organization in October, will be ready for rollout in <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization#:%7E:text=High%20efficacy%20when%20given%20just,following%20a%203%2Ddose%20series.">mid-2024</a>.</em></p>
<p><em>Rose Leke, winner of the <a href="https://virchowprize.org/2023-laureate/">2023 Virchow Prize </a>for her lifetime achievement in strengthening global health and a prominent voice in vaccine protocols, sheds light on the breakthroughs.</em></p>
<h2>Why are the vaccines significant for Africa?</h2>
<p>There are about <a href="https://theconversation.com/we-could-eradicate-malaria-by-2040-says-expert-after-revolutionary-vaccine-is-approved-by-who-214798">40 million children</a> born every year in malaria areas in Africa who would benefit from a vaccine. </p>
<p>The RTS,S/AS01 vaccine reduces malaria deaths by <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">30%</a> and is especially important for children, who are most at risk from malaria. If you had 100 children who would die from severe malaria, you could save 30. </p>
<p>Mothers who have had their children vaccinated in the pilot phase have expressed appreciation for the vaccine because it has prevented their children from dying of <a href="https://www.who.int/news-room/feature-stories/detail/mothers-in-malawi-value-the-first-malaria-vaccine">severe malaria</a>. </p>
<p>The second vaccine, <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization">R21/Matrix-M</a>, is highly effective, reducing cases of malaria by 75%. <a href="https://theconversation.com/we-could-eradicate-malaria-by-2040-says-expert-after-revolutionary-vaccine-is-approved-by-who-214798">Hundreds of millions</a> of doses of this vaccine can be produced each year. </p>
<p>It will be ready for rollout as early as <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization#:%7E:text=High%20efficacy%20when%20given%20just,following%20a%203%2Ddose%20series">mid-2024</a></p>
<p>These two vaccines are new tools, but they have to be used with the other measures we have against malaria. These include bed nets and the administration of antimalarials to children at the highest risk of malaria at specific times throughout the year. </p>
<p>If we add the vaccine on top of these measures effectively, we may move further towards malaria <a href="https://theconversation.com/we-could-eradicate-malaria-by-2040-says-expert-after-revolutionary-vaccine-is-approved-by-who-214798">elimination</a>. </p>
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Read more:
<a href="https://theconversation.com/we-could-eradicate-malaria-by-2040-says-expert-after-revolutionary-vaccine-is-approved-by-who-214798">'We could eradicate malaria by 2040' says expert after revolutionary vaccine is approved by WHO</a>
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<h2>How can all communities benefit?</h2>
<p>There is great demand for malaria vaccines. The demand is estimated to be <a href="https://cdn.who.int/media/docs/default-source/immunization/mvip/first_malaria_vaccine_allocation_explained_may2023.pdf?sfvrsn=248c4624_4">40 to 60 million doses</a> by 2026 alone. </p>
<p><a href="https://www.gavi.org/">Gavi</a>, the Vaccine Alliance, has given the nod to Benin, the Democratic Republic of Congo and Uganda among 12 countries in Africa to receive the first doses of the vaccine. They will be allocated a total of <a href="https://cdn.who.int/media/docs/defaultsource/immunization/mvip/first_malaria_vaccine_allocation_explained_may2023.pdf?sfvrsn=248c4624_4">18 million</a> vaccines for the period up to 2025. </p>
<p>Gavi is an international organisation created in 2000 to improve access to new and underused vaccines for children living in the world’s poorest countries.</p>
<p>So as you can see demand has been far greater than supply. When we had just one vaccine, the RTS/S, quantities were limited, and the WHO had to develop an equitable framework for the distribution of the limited doses. </p>
<p>Countries were categorised. Those in category 1 were most in need and the first to be vaccinated.</p>
<p>I was a little bit worried about this. If somebody came to my country, and they were vaccinating in a category 1 village and 20km away, in a category 2 village, a child could not get the vaccine, that would cause a problem socially and even politically. </p>
<p>I was <a href="https://cdn.who.int/media/docs/default-source/immunization/mvip/framework-for-allocation-of-limited-malaria-vaccine-supply.pdf?sfvrsn=35b12e4_2&download=true">co-chair</a> of the WHO panel looking into this. We spent a lot of time on the <a href="https://cdn.who.int/media/docs/default-source/immunization/mvip/first_malaria_vaccine_allocation_explained_may2023.pdf?sfvrsn=248c4624_4">framework</a>, trying to work out who gets it and who doesn’t. </p>
<p>These are the principles we followed:</p>
<ul>
<li><p>Areas of greatest need: where the malaria disease burden in children is highest and the risk of death is highest.</p></li>
<li><p>Where the expected health impact is greatest: where most lives can be saved with the limited available doses.</p></li>
<li><p>Countries that committed to fairness in their vaccination programmes.</p></li>
</ul>
<p>One of the criteria was that once the new vaccine was introduced through routine public health services in a certain area, <a href="https://cdn.who.int/media/docs/default-source/immunization/mvip/first_malaria_vaccine_allocation_explained_may2023.pdf?sfvrsn=248c4624_4">continuous and sustainable</a> access needed to be maintained. </p>
<h2>Why is local manufacturing so important?</h2>
<p>During <a href="https://www.wipo.int/wipo_magazine/en/2022/04/article_0005.html">COVID,</a> we saw that Africa was at the back of the queue. The best way to secure supply is to make it yourself.</p>
<p>That’s why vaccine manufacturing in Africa is one of the <a href="https://africacdc.org/news-item/a-new-deal-for-african-health-security/">Africa Centres for Disease Control’s</a> biggest priorities. </p>
<p>I hope that in my lifetime I will see some of these vaccines being produced on the continent.</p>
<h2>Not all people want the vaccinations, do they?</h2>
<p>My experience in Africa is that routine immunisation coverage is still quite <a href="https://www.afro.who.int/health-topics/immunization#:%7E:text=Approximately%201%20in%205%20African,VPDs">low</a>. Now we’re going to add this new malaria vaccine. If we have low vaccination rates, we will never get the impact we want. </p>
<p>So we always have to encourage mothers to take the children for vaccinations, and vaccine <a href="https://www.researchgate.net/publication/366944062_The_impact_of_information_sources_on_COVID-19_vaccine_hesitancy_and_resistance_in_sub-Saharan_Africa">hesitancy</a> should really be stopped. </p>
<p>There’s the <a href="https://journals.co.za/doi/full/10.10520/ejc-ajgd_v10_n1_1_a4">belief</a> that these foreign vaccines are coming to kill the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8115834/">children</a>. But what <em>haven’t</em> we imported? Is it milk? Is it soap? Is it sardines? </p>
<p>Why is it only with vaccines that people have these theories? </p>
<p>Vaccines have been so effective, the<a href="https://www.afro.who.int/health-topics/immunization"> impact</a> on the African continent has been so great.</p>
<p>Most of us, even me and you, might have been gone without vaccines. We need to inform people to get rid of this vaccine hesitancy that we have all over the continent.</p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2023 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/217146/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose Leke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The past two years have seen groundbreaking advances in the fight against malaria with the development of two vaccines. But demand far exceeds supply, so rollouts need to be carefully managed.Rose Leke, Professor of Immunology and Parasitology, Faculty of Medicine and Biomedical Sciences, Université de Yaounde 1Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2176932023-11-17T13:21:44Z2023-11-17T13:21:44ZAntimicrobial resistance is a silent killer that leads to 5 million deaths a year. Solutions must include the poor<p>Microbes such as bacteria, viruses, parasites and fungi form part of our everyday lives – they live in us, on us and around us. </p>
<p>We need them for healthy digestion, immune function, and the synthesis of essential nutrients, and we depend on them for farming and industrial processes.</p>
<p>But microbes also cause disease in people, animals and plants. That is why science has developed an arsenal of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8995183/">antimicrobials</a> that kill them or slow their spread.</p>
<p>Over time, microbes develop resistance to antimicrobials, and some eventually evolve into so-called “superbugs” that no longer respond to the drugs. So we see more and more <a href="https://pubmed.ncbi.nlm.nih.gov/29773743/">untreatable infections</a> appearing in hospitals and communities.</p>
<p>This phenomenon, known as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4768623/">antimicrobial resistance</a> (AMR), means that common illnesses and diseases may become life-threatening again.</p>
<p>Recent figures show that antimicrobial resistance has been linked to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext">close to 5 million deaths annually</a> – more than the total combined death toll of HIV/AIDS and malaria. </p>
<p>It is further estimated that deaths related to drug-resistance <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">could increase to 10 million per year</a> by 2050, overtaking cancer as a leading cause of death worldwide.</p>
<p><a href="https://www.who.int/news-room/events/detail/2023/11/18/default-calendar/world-amr-awareness-week-2023#:%7E:text=WAAW%20is%20celebrated%20from%2018,It%20affects%20us%20all.">World AMR Awareness Week</a> aims to improve awareness and understanding of this silent killer. </p>
<h2>Remembering the poor</h2>
<p>We need urgent global action to counter antimicrobial resistance. However, current efforts that focus on solutions developed in high-income settings may not be suited to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861125/">societal and economic challenges in low- and middle-income countries</a>.</p>
<p>We are members of a multidisciplinary <a href="https://www.thebritishacademy.ac.uk/projects/just-transitions-to-contain-antibiotic-resistance-while-minimising-potential-burdens-and-harms/">Global Convening Programme</a> set up by <a href="https://www.thebritishacademy.ac.uk/">The British Academy</a> to look into solutions to this problem that are fair and inclusive. Our collective expertise includes science communication, epidemiology, ethics and human rights.</p>
<p>If we want people to become less dependent on antibiotics, we must address <a href="https://www.nature.com/articles/s41586-021-03694-x">the factors that create dependency on antibiotics in the first place</a>.</p>
<p>Antimicrobial resistance is a global issue, but there are some regional differences. </p>
<p><a href="https://doi.org/10.1016/S0140-6736(21)02724-0">Most human deaths from antimicrobial resistance occur in sub-Saharan Africa</a>. Drug resistance is a growing concern in <a href="https://hal.science/hal-02559257/file/1-s2.0-S1473309918300719-main.pdf">malaria</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/30339803/">tuberculosis</a> in these regions.</p>
<p>Low-income environments often go hand in hand with the use of cheap antimicrobials that may be of poor quality or even falsified. These create the <a href="https://www.ncbi.nlm.nih.gov/books/NBK97126/">ideal conditions for resistance to emerge</a>.</p>
<p>Many are sold over the counter for self-diagnosed ailments. </p>
<h2>Antibiotics, animals and pandemic risk</h2>
<p>Antibiotics are among the most widely used antimicrobials. Between 2000 and 2015 the use of antibiotics increased by <a href="https://www.pnas.org/doi/abs/10.1073/pnas.1717295115?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed">65%</a> worldwide. </p>
<p>Globally, however, more antibiotics are used in <a href="https://www.science.org/doi/10.1126/science.aao1495">animals</a> and agriculture than for human health. Of all antimicrobials, <a href="https://doi.org/10.1371/journal.pgph.0001305">73%</a> are used in animals raised for food. </p>
<p>In September 2016, the United Nations adopted a unanimous <a href="https://digitallibrary.un.org/record/845917">resolution</a> recognising the inappropriate use of <a href="https://www.science.org/doi/10.1126/science.aao1495">antimicrobials in animals</a> as a leading cause of rising antimicrobial resistance. </p>
<p>Farmers rely on antibiotics to prevent disease outbreaks and <a href="https://www.nature.com/articles/s41599-018-0152-2">boost</a> production, especially where animals are kept in unhygienic and overcrowded conditions, and where farmers don’t have access to veterinary care. There antibiotics serve as “<a href="https://gh.bmj.com/content/4/4/e001590">quick fixes</a>”.</p>
<p>In one study in rural Uganda a woman told researchers she was using left-over antibiotics to treat family members and her chickens. This repurposing of antibiotics is seen as a way to <a href="https://www.tandfonline.com/doi/full/10.1080/01459740.2022.2047676">survive and make a living</a>.</p>
<p>Experts warn that antimicrobial resistance in <a href="https://www.science.org/doi/10.1126/science.aaw1944">farm animals</a>, if unchecked, could lead to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9200017/pdf/JNMA-60-246-225.pdf">next pandemic</a>.</p>
<h2>Everybody is exposed, everywhere</h2>
<p>Environmental pollution in the form of <a href="https://wellcome.org/sites/default/files/antimicrobial-resistance-environment-report.pdf">antimicrobial residues spreads</a> to soils, rivers, streams and oceans, as well as food and drinking water, and contributes to resistance. Everyone is exposed to antimicrobials, especially antibiotics, even if they don’t take these medicines themselves. </p>
<p>This kind of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8995183/">pollution</a> is aggravated when antimicrobials are used and disposed of negligently. </p>
<h2>The global response needs to be fair to all</h2>
<p>We are calling for a new approach to antimicrobial resistance that prioritises <a href="https://doi.org/10.1016/S0140-6736(23)01687-2">equity and sustainability</a>. </p>
<p>Policy options must be carefully considered with all those involved and by <a href="https://www.medrxiv.org/content/10.1101/2023.10.06.23296658v1">embedding public and community voices</a> without having pre-determined solutions in mind. </p>
<p>“Simple” solutions may disadvantage communities that shoulder the heaviest burden of infections and poor healthcare. For example, banning the over-the-counter sale of antibiotics may help to curb excessive use, but it could also deny life-saving treatment for people who have no other options. Similarly, without antibiotics, small-scale pig and poultry farmers may <a href="https://pubmed.ncbi.nlm.nih.gov/36762463/">no longer be able to make a living</a>. </p>
<p>The solution we are working towards is fair and inclusive. It respects people and their traditions while also benefiting human health, animal welfare and the natural environment.</p><img src="https://counter.theconversation.com/content/217693/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marina Joubert receives funding from The British Academy. </span></em></p><p class="fine-print"><em><span>Sonia Lewycka receives funding from The British Academy and Wellcome. </span></em></p><p class="fine-print"><em><span>Phaik Yeong Cheah does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Antimicrobial resistance is an epidemic that kills close to 5 million people annually. The solutions are complex and must take into account the needs of the poor.Marina Joubert, Science Communication Researcher, Stellenbosch UniversityPhaik Yeong Cheah, Professor of Global Health, University of OxfordSonia Lewycka, Epidemiologist, Oxford University Clinical Research Unit (OUCRU)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2164832023-10-27T14:09:00Z2023-10-27T14:09:00ZChad’s first dengue fever outbreak: what you should know<p><em>Chad has <a href="https://www.cidrap.umn.edu/dengue/chad-reports-its-first-dengue-outbreak">reported</a> its first dengue outbreak, according to the World Health Organization (WHO). The country’s health ministry declared an outbreak on 15 August and so far 1,342 suspected cases have been reported, 41 of them confirmed in the laboratory. One death was reported among the patients with lab-confirmed cases. The outbreak started in Ouaddaï province in eastern Chad, currently the outbreak epicentre. Illnesses have also been reported in three other provinces. Godfred Akoto Boafo spoke to medical entomologist Eunice Anyango Owino about the disease.</em></p>
<h2>What causes dengue fever and how does it affect people?</h2>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue">Dengue fever</a> is a mosquito-borne viral disease caused by one of the four dengue virus serotypes. It is primarily transmitted by the <em>Aedes aegypti</em> mosquito and to a lesser extent the <em>Aedes albopictus</em> mosquito, mainly in the tropical and sub-tropical areas of the world. </p>
<p>Infection with one serotype provides long-term immunity to that particular serotype, but not the others. That means that, after recovery, a person can still be infected by the other three serotypes. Serotypes are groups within a single species of microorganisms, such as bacteria or viruses, which share distinctive surface structures.</p>
<p>Most infections produce only mild flu-like illness; 80% of cases are asymptomatic. But getting infected with different serotypes one after the other puts a person at a greater risk of severe dengue, also known as dengue hemorrhagic fever. It is characterised by serious internal bleeding and organ damage, and a sudden drop in blood pressure that causes shock which can be fatal. </p>
<h2>How widespread is it in the Sahel? Why is this first outbreak in Chad significant?</h2>
<p>Dengue fever has been <a href="https://pubmed.ncbi.nlm.nih.gov/37473544/">endemic in Sudan</a>, with outbreaks documented in 2010, 2013, 2017 and 2019. Unfortunately, due to years of political and civil conflicts, the control and response capacity of the public health sector in Sudan has been limited. </p>
<p>The risk of spread in the Sahel region, which includes Niger, Mali and Chad, has always been high. This is because these countries all host the suitable mosquito vectors (<em>Aedes</em>). They also share the same tropical climate with seasonal heavy rains and floods. </p>
<p>To add to the problem, countries like Chad are grappling with a massive influx of refugees and returnees from Sudan who might be carrying the disease. The epicentre of the current outbreak, the <a href="https://www.unocha.org/publications/report/chad/chad-humanitarian-update-june-2023#:%7E:text=Following%20the%20escalation%20of%20conflict%20in%20El%20Geneina,Sudanese%20border%20in%20the%20Ouadda%C3%AF%20province%20of%20Chad">province of Ouaddaï</a> at the eastern border with Sudan, hosts more than 400,000 refugees. </p>
<p>The cities at the border with Sudan are densely populated and have poor sanitation. This provides a favourable environment for the vectors to breed. </p>
<p>In addition, Chad lacks effective disease control programmes. This is its first dengue outbreak. It doesn’t have the necessary public health preparedness and response capacities. So the risk posed by this outbreak is high. </p>
<p>The movement of the <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2019-DON207">returning refugees</a> has the potential to spread the outbreak in Chad and even across the border to other countries in the Sahel, the rest of Africa, and the world at large. </p>
<h2>What treatment is available?</h2>
<p>There’s currently no available treatment for dengue in the world. Timely detection and case management, especially treatment of dehydration and plasma leakage by oral or intravenous rehydration, are key in preventing severe illness and death. </p>
<p>There is an approved dengue vaccine (Dengvaxia) for use in people aged 9-45 years. But for it to be effective they must have had one infection of dengue by any of the four serotype viruses, which must be confirmed by a laboratory test. </p>
<p>The vaccine is given in three doses within 12 months and protects against all the four dengue virus serotypes with an efficacy of 80%. However, its availability in developing countries in Africa isn’t assured, although it has been licensed by several national regulatory authorities. </p>
<p>Apart from the vaccine, the only other guard against dengue fever is prevention of mosquito bites and vector control.</p>
<h2>What is the way forward in controlling the disease?</h2>
<p>More investment should be put on expanding clinical and laboratory capabilities to deal with the disease. Given that this is Chad’s first outbreak, it needs to:</p>
<ul>
<li><p>put in place standard operating procedures for clinical management of suspected and confirmed dengue cases </p></li>
<li><p>expand the capacity for early detection of cases – this could be done by procurement of rapid diagnostic tests and by alerting communities </p></li>
<li><p>strengthen disease surveillance and coordinate the response by actively finding cases. Cases within the community are likely to be underreported as dengue is unknown to the public. Also, clinicians might not be familiar with the disease presentation. It could be confused with other common fevers. </p></li>
<li><p>put in place effective vector control measures, like draining stagnant water around residential areas, cleaning and replenishing water storage containers on a weekly basis, distributing insecticide-treated nets, spraying indoors and using window and door screens.</p></li>
<li><p>strengthen surveillance to assess the vector breeding potential in containers and to monitor insecticide resistance. This is critical for selecting the most effective insecticides. </p></li>
<li><p>make communities aware of the risks of infection and how to protect themselves. Engaged communities can take ownership of the vector control strategy and adopt healthy behaviours. </p></li>
<li><p>strengthen cross-border collaboration. The current outbreak most likely spread from Sudan. The focus should be on prevention and vector control measures in border areas.</p></li>
<li><p>mobilise resources for a national contingency plan for dengue preparedness and response. And seek help from experienced organisations like the WHO.</p></li>
</ul><img src="https://counter.theconversation.com/content/216483/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eunice Anyango Owino receives funding from National Research Fund, Kenya. </span></em></p>The Sahel region is grappling with an outbreak of the deadly mosquito-borne disease.Eunice Anyango Owino, Medical Entomologist at the School of Biological Sciences, University of NairobiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2150522023-10-05T04:04:34Z2023-10-05T04:04:34ZNew malaria vaccine: no silver bullet but an important step towards eradication<p>In what was very big news for global health, this week the <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization">World Health Organisation</a> (WHO) recommended a new vaccine for the prevention of malaria in children, called R21/Matrix-M.</p>
<p>Malaria, caused by infection with <em>Plasmodium</em> parasites and transmitted via mosquitoes, still causes many millions of cases and more than <a href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022">600,000 deaths annually</a>, the majority in children under five and pregnant women in Africa. </p>
<p>This is the second malaria vaccine to be endorsed by the WHO, following a vaccine called <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">RTS,S/AS01</a> in 2021. </p>
<p>Both are much-needed tools in the global fight to eradicate malaria, with the potential to save millions of lives. But the new vaccine offers some unique advantages.</p>
<h2>First, how the malaria vaccines work</h2>
<p>Both the <a href="https://www.nature.com/articles/srep46621">newly endorsed vaccine</a>, R21, and the <a href="https://www.tandfonline.com/doi/full/10.1080/21645515.2019.1669415">earlier vaccine</a>, RTS,S, aim to protect against malaria by blocking the <em>Plasmodium falciparum</em> parasite before it can cause infection. They do this by targeting the parasite during the bite from a mosquito. </p>
<p>Called “sub-unit” vaccines, they contain a single protein from <em>P. falciparum</em>, the circumsporozoite protein, which coats the surface of the parasite. The vaccines aim to drive an immune response that can subsequently recognise the circumsporozoite protein, and kill the parasite before it causes infection. </p>
<p>It’s a bit like how most COVID vaccines target the “spike” protein, a protein on the surface of SARS-CoV-2 (the virus that causes COVID) to block the virus.</p>
<p>Both malaria vaccines are administered with an adjuvant, a special formula to help activate the immune response. They contain the same parasite protein target, but are designed with different amounts of parasite protein, and unique adjuvants. </p>
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<em>
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Read more:
<a href="https://theconversation.com/worlds-first-mass-malaria-vaccine-rollout-could-prevent-thousands-of-children-dying-169457">World's first mass malaria vaccine rollout could prevent thousands of children dying</a>
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<h2>Efficacy and access</h2>
<p>New <a href="http://dx.doi.org/10.2139/ssrn.4584076">results</a> from phase 3 trials of R21 show the vaccine can prevent up to 75% of malaria cases over the year following vaccination. This is in areas where malaria occurs seasonally and when the vaccine is used in combination with other preventive measures including drugs. It’s important to note this data has not yet been peer-reviewed.</p>
<p>Peer-reviewed <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60721-8/fulltext">phase 3 trials of RTS,S</a> showed the vaccine can prevent around 56% of cases in the year following vaccination across a large number of malaria infection sites. </p>
<p>These vaccines haven’t been tested directly against each other, so we can’t say conclusively whether one vaccine is more effective than the other, though it seems possible that R21 offers enhanced protection. </p>
<figure class="align-center ">
<img alt="A mosquito on skin." src="https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552234/original/file-20231005-19-jqtpoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">There are more than 600,000 deaths globally from malaria each year.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/dangerous-malaria-infected-mosquito-skin-bite-1483138139">nechaevkon/Shutterstock</a></span>
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<p>R21 also has significant advantages when it comes to manufacturing, supply and cost, with <a href="http://dx.doi.org/10.2139/ssrn.4584076">100-200 million doses</a> predicted to be available annually from existing manufacturers in India. Because of this, and with the ability for manufacturing to be expanded to other malaria-endemic countries, the cost of R21 will be less than <a href="http://dx.doi.org/10.2139/ssrn.4584076">US$5 a dose</a> (compared to only around 15 million doses for RTS,S at nearly <a href="https://www.unicef.org/supply/media/13396/file/Malaria-Vaccine-Supply-Price-Market-Questions-Answers-August2022.pdf">twice the cost</a> per dose). </p>
<p>The availability of the R21 vaccine should make access and rollout across malaria-endemic areas feasible in the coming years.</p>
<h2>Will this vaccine eradicate malaria?</h2>
<p>The short answer is no, but it promises to help a great deal.</p>
<p>Despite the impressive protection reported from the R21 vaccine, challenges remain. The vaccine requires <a href="http://dx.doi.org/10.2139/ssrn.4584076">three doses over three months</a> in the first instance, followed by a booster dose one year later. It also seems likely that yearly boosters will be required to maintain protection. </p>
<p>As we’ve seen in the rollout of COVID vaccines, boosters are challenging to administer even in areas such as Australia with very strong health systems. To date, neither of the malaria vaccines have been integrated within other childhood vaccination programs, placing an additional burden on communities.</p>
<p>Further, R21 is yet to be tested in an area of very high malaria risk. Results from the RTS,S vaccine flag this as a concern, because in areas of high malaria transmission there is a risk that <a href="https://dx.doi.org/10.1126/scitranslmed.aau1458">previous infection</a> can block the efficacy of vaccines, leaving those most at risk with reduced protection.</p>
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<strong>
Read more:
<a href="https://theconversation.com/the-long-road-to-a-new-malaria-vaccine-told-by-the-scientists-behind-the-breakthrough-podcast-214885">The long road to a new malaria vaccine, told by the scientists behind the breakthrough – podcast</a>
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<p>Finally, both endorsed vaccines only target one type of malaria, that caused by <em>P. falciparum</em> parasites. This is the <a href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022">most deadly</a> form of malaria, so it’s understandable that vaccine efforts have focused on this species. </p>
<p>But it’s important to note that these vaccines don’t protect against other types of malaria, most especially <em><a href="https://www.vivaxmalaria.org/">Plasmodium vivax</a></em>, which causes the most disease in southeast Asia.</p>
<p>Further research and development will be needed to develop second-generation malaria vaccines. Especially important will be vaccines that induce high levels of sustained protection without the need for yearly boosters, vaccines that protect against all malaria types (particularly <em>P. vivax</em>), and vaccines or additional drugs that can boost protection for children who have the highest malaria risk.</p>
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<img alt="A group of happy African schoolchildren." src="https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552237/original/file-20231005-23-9bofx9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The R21 vaccine will be given to children in countries where malaria is endemic.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-african-schoolgirls-playground-waving-camera-668003338">Monkey Business Images/Shutterstock</a></span>
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<h2>Multiple layers of protection</h2>
<p>While not a silver bullet, the availability of two malaria vaccines is an exciting development. </p>
<p>We’ve seen with the COVID pandemic that vaccines can have a significant individual and public health impact when used alongside other tools. Likewise, it’s essential that malaria control strategies make integrated use of all available interventions. </p>
<p>The use of these two vaccines, with continued use of preventive drugs, insecticide-treated bed nets, fast and effective drug treatments, and other control tools, will make a big difference and save lives.</p>
<p>Many of us in the field wondered if we would ever see an approved malaria vaccine. As WHO director-general <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization">Tedros Adhanom Ghebreyesus said</a>, “As a malaria researcher, I used to dream of the day when we would have a safe and effective vaccine against malaria. Now we have two.”</p><img src="https://counter.theconversation.com/content/215052/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Boyle receives funding from the Snow Medical Research Foundation, CSL, National Health and Medical Research Council, and National Institutes of Health to understand immunity to malaria and to develop approaches of host directed therapies to improve immunity. </span></em></p><p class="fine-print"><em><span>Brendan Crabb and the Institute he leads receives research grant funding from the National Health & Medical Research Council of Australia, the Medical Research Future Fund, DFAT's Centre for Health Security and other Australian federal and Victorian State Government bodies. He is the Chair of The Australian Global Health Alliance and the Pacific Friends of Global Health, both in an honorary capacity. And he serves on the Board of the Telethon Kids Institute, on advisory committees of mRNA Victoria, the Sanger Institute (UK), the Institute for Health Transformation (at Deakin University), The Brain Cancer Centre (Australia), the WHO Malaria Vaccine Advisory Committee; MALVAC, and is a member of OzSAGE and The John Snow Project, all honorary positions.</span></em></p>Currently we see more than 600,000 deaths from this mosquito-borne disease each year. This new vaccine – the second approved to treat malaria – could change things.Michelle Boyle, Snow Medical Fellow & CSL Centenary Fellow, Burnet InstituteBrendan Crabb, Director and CEO, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2147982023-10-03T19:50:49Z2023-10-03T19:50:49Z‘We could eradicate malaria by 2040’ says expert after revolutionary vaccine is approved by WHO<p><em>The World Health Organization has <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization">approved</a> a new vaccine that scientists argue will be a game-changer in the fight against malaria, which kills half a million people in Africa every year. Trials have shown that the <a href="https://www.ox.ac.uk/news/2023-10-02-oxford-r21matrix-m-malaria-vaccine-receives-world-health-organization-recommendation">R21/Matrix vaccine</a>, developed by Oxford University together with the Serum Institute of India, reduces malaria by up to 75%. It can be manufactured cheaply and on a mass scale. The Conversation Weekly spoke to chief investigator Adrian Hill, who is also director of the Jenner Institute at the University of Oxford, about this revolutionary vaccine. Below are edited excerpts from the <a href="https://theconversation.com/the-long-road-to-a-new-malaria-vaccine-told-by-the-scientists-behind-the-breakthrough-podcast-214885">podcast</a>.</em></p>
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<h2>Why is the R21/Matrix vaccine a game-changer?</h2>
<p>We’re seeing about 75% efficacy by counting the reduction in numbers of malaria episodes over a year. The best vaccine prior to this was about 50% over a year, and lower than that over three years.</p>
<p>This is a material improvement, but that’s not the main improvement. The big difference is how you can manufacture it at a scale that is really needed to protect most of the children who need a malaria vaccine in Africa. </p>
<p>There are about 40 million children born every year in malaria areas in Africa who would benefit from a vaccine. Ours is a four-dose vaccine over 14 months, so you need about 160 million doses. We can achieve that. </p>
<p>The Serum Institute of India, our manufacturing and commercial partner, can produce hundreds of millions of doses of this vaccine each year, whereas the previous vaccine could be manufactured at a scale of six million doses a year from 2023 to 2026, according to Unicef reports. </p>
<p>The third real advantage of this vaccine is its cost. We were well aware that we couldn’t produce a US$100 vaccine. It wouldn’t fly for international agencies supporting the purchase and distribution of the vaccine in very low-income countries.</p>
<p>So where we are now is a price that’ll vary according to the scale, but at high volume it should be US$5 a dose.</p>
<h2>Why has developing a malaria vaccine been so difficult?</h2>
<p>People have been trying to make malaria vaccines for over 100 years. Well over 100 vaccines have gone into clinical trials in people. Very, very few have worked to any degree.</p>
<p>Malaria is not a virus, it’s not a bacterium. It’s a protozoan parasite, some thousands of times larger than a typical virus. A good measure of that is how many genes it has. Covid has 13, malaria has about 5,500. This is one of the reasons that malaria is super complex.</p>
<p>There are different parasite forms the first of which are injected by the mosquito into the skin and rapidly go to the liver. They spend a week multiplying there, and then they go into the bloodstream. And they are hugely different during these different stages. And the parasites grow at a rate of tenfold every 48 hours, multiplying furiously. </p>
<p>By the time they get to a really high parasite density, you will be very unwell. Or if you’re unlucky, you will die, typically from cerebral symptoms, a coma or from being severely anaemic. The parasites break open the red blood cells.</p>
<p>And then there’s yet another stage where the parasite changes again to a form that the mosquito can take up through its next bite and continue the life cycle by infecting somebody else.</p>
<p>So this is as complex as it gets with infectious pathogens.</p>
<p>Malaria typically goes through four life cycles and they’re all different. If you can get a really good vaccine for one of those, you will break the cycle of transmission. And that’s what we’ve been trying to do.</p>
<p>We’ve been working on targeting the so-called sporozoites, which is the form that the mosquito inoculates into your skin. We’re trying to trap it before it can get to the liver and carry on the life cycle.</p>
<p>Luckily, there are no symptoms of malaria at that stage. It’s a silent infection until it gets into the blood and starts multiplying inside your red blood cells. </p>
<p>So the sporozoite is a natural target to try and kill the parasite before it multiplies very quickly.</p>
<h2>Tell us about past attempts to develop a malaria vaccine</h2>
<p>Very early on people tried to use the whole microbe in the same way that vaccine pioneer Edward Jenner used the whole virus to inoculate against smallpox. Then the French microbiologist Louis Pasteur came along with bacterial vaccines, and so on.
In about 1943, there was a trial of the whole malaria parasite vaccine candidate in New York with zero efficacy. That put people off for a while.</p>
<p>It wasn’t until the 1980s when we could actually begin to sequence the genes in the parasite that new vaccination candidates appeared. And then within 10 years we had 5,000 candidates because everyone hoped that the gene they had sequenced might be a malaria vaccine. And of course almost all of those failed.</p>
<h2>Why aren’t vaccines for whole parasites effective against malaria?</h2>
<p>It’s the same reason that just getting infected once by malaria doesn’t give you protection against the next infection. </p>
<p>In the areas of malaria where we test our vaccines in Africa, some children get up to eight episodes in three or four months. They get quite unwell with the first and three weeks later they’re having a second bout and so on. Natural immunity doesn’t work until you’ve had a lot of different infections and that’s why adults are generally protected against malaria and don’t become very unwell. </p>
<p>The people who die of malaria in an endemic area are the <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">young children </a> who may never have been infected before and die with their first infection when they’re one year old, or they might have had one or two episodes, but that wasn’t enough to give them sterilising immunity.</p>
<p>Malaria has been around for tens of millions of years. Not just in humans, but in the species that we were before we became humans.</p>
<p>It’s a very wily parasite and has developed <a href="https://academic.oup.com/femsre/article/40/2/208/2570118">immune escape mechanisms </a> of all sorts.</p>
<p>When you try to vaccinate, you suddenly find there’s some way the parasite gets around that, and it’s only when you get up to really extraordinarily high levels of antibodies that the parasite hasn’t seen before and hasn’t learnt to evolve against that it becomes effective.</p>
<h2>Will we ever eradicate malaria entirely?</h2>
<p>Malaria is very high on the list of diseases we want to eradicate. I don’t think it’s going to happen in five years or 10 years, but it should happen in something like 15 years. So 2040 would be a reasonable target. </p>
<p>Nobody’s suggesting we stop doing what we’re doing at the moment with bed nets and spraying and drugs. But now we have a new tool that may be individually more protective than any of the tools we’re using at the moment.</p><img src="https://counter.theconversation.com/content/214798/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adrian Hill receives funding from government and charitable funders of malaria vaccine development. He has received funding awarded to the University of Oxford from the Serum Institute of India to support clinical trials of the R21/Matrix-M vaccine. He may benefit for a share of any royalty stream to Oxford University from the vaccine.</span></em></p>People have been trying to make malaria vaccines for over 100 years. With the help of the revolutionary new R21/Matrix vaccine the disease could be eradicated by 2040.Adrian Hill, Director of the Jenner Institute, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2148852023-10-03T14:19:16Z2023-10-03T14:19:16ZThe long road to a new malaria vaccine, told by the scientists behind the breakthrough – podcast<figure><img src="https://images.theconversation.com/files/551732/original/file-20231003-17-vu9c9t.jpg?ixlib=rb-1.1.0&rect=22%2C164%2C2807%2C1773&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-mosquito-sucking-blood-1430203604">Darkdiamond67 via Shutterstock</a></span></figcaption></figure><p>The world has waited decades for a malaria vaccine, and now two have come along in quick succession. On October 2, the World Health Organization (WHO) recommended that a new malaria vaccine, R21, developed by the University of Oxford be <a href="https://www.who.int/news/item/02-10-2023-who-recommends-r21-matrix-m-vaccine-for-malaria-prevention-in-updated-advice-on-immunization">rolled out for the prevention of malaria in children</a>, just two years after another vaccine, the RTS,S, got its endorsement. </p>
<p>In this episode of <em><a href="https://theconversation.com/uk/topics/the-conversation-weekly-98901">The Conversation Weekly</a></em> podcast, we find out why it’s been so hard to find a malaria vaccine – and hear from the scientists behind the new breakthrough.</p>
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<p>In 2021, <a href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022">619,000 people died from malaria</a>, the majority of them children. The search for a vaccine has been underway for decades, but it’s particularly difficult due to the complexity of the malaria parasite. </p>
<p>“It begins with a mosquito bite,” says Faith Osier, co-director of the Institute of Infection at Imperial College London. “It injects what we call sporozoite, a stage of the malaria parasite, that gets carried in your circulation into the liver and then it develops there”. About two weeks later, the parasites appear in the blood, morphing into different structures that are difficult to target with a vaccine. </p>
<p>But recent years have seen big breakthroughs in understanding what works. The RTS,S vaccine, which was developed by GSK, has been given to <a href="https://www.who.int/news/item/05-07-2023-18-million-doses-of-first-ever-malaria-vaccine-allocated-to-12-african-countries-for-2023-2025--gavi--who-and-unicef">1.7 million children in Ghana, Kenya and Malawi</a> since 2019. </p>
<p>In early October 2023, the WHO recommended the use of a second malaria vaccine, created by the University of Oxford, called R21, following the publication of <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4584076">results from phase III clinical trials</a> on children in Africa in a pre-print in The Lancet medical journal. </p>
<p>“We’re seeing about 75% efficacy of our vaccine,” says Adrian Hill, director of the Jenner Institute at the University of Oxford, which developed the new R21 vaccine. This means the vaccine can diminish “the number of clinical episodes that a child in Africa would get by 75%, compared to children who have not been vaccinated”. </p>
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Read more:
<a href="https://theconversation.com/we-could-eradicate-malaria-by-2040-says-expert-after-revolutionary-vaccine-is-approved-by-who-214798">'We could eradicate malaria by 2040' says expert after revolutionary vaccine is approved by WHO</a>
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<p>Alassane Dicko, a professor at the Malaria Research and Training Center at the University of Bamako in Mali, conducted one of the stages of the phase III trial. He told The Conversation Weekly that in some of the most vulnerable groups in their trial, babies between five and 17 months, “the efficacy was 80%” after 12 months. </p>
<p>For comparison, the <a href="https://microbiologycommunity.nature.com/posts/a-review-of-the-rts-s-malaria-vaccine-efficacy-impact-and-mechanisms-of-protection">RTS,S</a> vaccine showed around 55% efficacy after 12 months. </p>
<p>“It’s great to get higher efficacy, of course, but the big difference here with this vaccine is how you can manufacture it at a scale that is really needed to protect most of the children who need a malaria vaccine in Africa,” says Hill. </p>
<p>Oxford has been working with a partner, the Serum Institute of India, who it says has already established production capacity for 100 million doses a year. The higher volumes should also keep the cost of each dose relatively low. </p>
<p>To find out more about the vaccine, and what it means about the potential to fully eradicate malaria, listen to the full episode on <a href="https://podfollow.com/the-conversation-weekly/view">The Conversation Weekly</a> podcast. </p>
<p>A transcript of this <a href="https://cdn.theconversation.com/static_files/files/2997/Malaria_Vaccine_Transcript.pdf?1704360326">episode is now available</a>. </p>
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<p><em>This episode was written and produced by Katie Flood, with assistance from Gemma Ware and Mend Mariwany. Eloise Stevens does our sound design, and our theme music is by Neeta Sarl.</em></p>
<p><em>You can find us on Twitter <a href="https://twitter.com/TC_Audio">@TC_Audio</a>, on Instagram at <a href="https://www.instagram.com/theconversationdotcom/">theconversationdotcom</a> or <a href="mailto:podcast@theconversation.com">via email</a>. You can also subscribe to The Conversation’s <a href="https://theconversation.com/newsletter">free daily email here</a>.</em></p>
<p><em>Listen to <em>The Conversation Weekly</em> via any of the apps listed above, download it directly via our <a href="https://feeds.acast.com/public/shows/60087127b9687759d637bade">RSS feed</a> or find out <a href="https://theconversation.com/how-to-listen-to-the-conversations-podcasts-154131">how else to listen here</a>.</em></p><img src="https://counter.theconversation.com/content/214885/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adrian Hill receives funding from government and charitable funders of malaria vaccine development. He may benefit for a share of any royalty stream to Oxford University from the R21/MM vaccine. Alassane Dicko received grants from the Serum Institute of India, the Medical Research Council, the National Institute of Allergy and Infectious Diseases and Grand Challenges to conduct research on malaria vaccines. </span></em></p><p class="fine-print"><em><span>Faith Osier does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In this episode of The Conversation Weekly, we hear from the scientists behind a new malaria vaccine developed by the University of Oxford.Daniel Merino, Associate Science Editor & Co-Host of The Conversation Weekly Podcast, The ConversationNehal El-Hadi, Science + Technology Editor & Co-Host of The Conversation Weekly Podcast, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2117032023-08-18T13:16:43Z2023-08-18T13:16:43ZHow genetically modifying mosquitoes could strengthen the world’s war on malaria<figure><img src="https://images.theconversation.com/files/543058/original/file-20230816-19-7rtxgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Genetic modification could make malaria-carrying mosquitoes harmless.</span> <span class="attribution"><span class="source">LeliaSpb/Getty Images</span></span></figcaption></figure><p>It’s been 126 years since British medical doctor Sir Ronald Ross <a href="https://www.nobelprize.org/prizes/medicine/1902/ross/facts/">discovered</a> that mosquitoes in the <em>Anopheles</em> family are primarily responsible for transmitting malaria parasites between vertebrate hosts. </p>
<p>Since his discovery, mosquitoes have been found to carry and transmit <a href="https://theconversation.com/mosquitoes-theres-malaria-plus-5-other-diseases-they-pass-on-to-humans-188856">many other diseases</a> that pose a major threat to public health. <a href="https://theconversation.com/mosquitoes-theres-malaria-plus-5-other-diseases-they-pass-on-to-humans-188856">Among them</a> are yellow fever, dengue and <a href="https://theconversation.com/understanding-zikas-silent-presence-in-africa-is-key-to-tackling-the-next-epidemic-80343">Zika</a>.</p>
<p>Currently, malaria is the most lethal mosquito-transmitted disease. The World Health Organization (WHO) <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">reported</a> an estimated 247 million cases of malaria worldwide in 2021 and 619,000 deaths. <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">Almost all cases and deaths</a> were in African countries.</p>
<p>Other diseases transmitted by mosquitoes are also a source of immense human suffering. It is <a href="https://www.worldmosquitoprogram.org/en/learn/mosquito-borne-diseases#:%7E:text=Common%20types%20of%20mosquito%2Dborne,chikungunya%2C%20yellow%20fever%20and%20Zika">estimated</a> that dengue infects about 390 million people annually. And thousands are affected by Zika, chikungunya and yellow fever. </p>
<p>Insects that transmit diseases to humans are known as vectors and the diseases they transmit are referred to as vector-borne diseases. These diseases are very difficult to control. They generally have complex life cycles, involving both the insect and the human host.</p>
<p>Conventional methods to control vector-borne diseases have targeted the vectors, focusing on reducing their opportunities to come into contact with humans. </p>
<p>This is <a href="https://www.who.int/teams/global-malaria-programme/prevention/vector-control#:%7E:text=Vector%20control%20is%20a%20highly,areas%20at%20risk%20of%20malaria">particularly true for malaria</a>. Insecticide-treated nets serve a dual function by acting as a physical barrier between the mosquito vector and humans, and exposing the mosquito to a lethal dose of insecticide when it lands on the net. In another common control method, mosquitoes are exposed to a lethal dose of insecticide through indoor residual spraying.</p>
<p>Both nets and indoor spraying have played <a href="https://endmalaria.org/sites/default/files/Kleinschmidt%20Immo_IRS%20and%20ITN%20combined%20effect.pdf#page=7">a major role</a> in reducing African countries’ malaria burden. But their sustained efficacy is under threat. Many vector populations have <a href="https://www.who.int/teams/global-malaria-programme/prevention/vector-control/insecticide-resistance">become resistant</a> to the insecticides used in these methods. They have also <a href="https://www.pbs.org/wgbh/nova/article/mosquito-behavioral-resistance/">changed their behaviours</a> to reduce their contact with those insecticides. </p>
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<p>Scientists <a href="https://www.ivcc.com/research-development/insecticide-discovery-and-development/">are working</a> to address these issues. But other methods that don’t rely on insecticides are needed in the fight against mosquito-borne diseases. </p>
<p>That’s where genetic modification comes in. We are researchers focused on finding novel ways to advance malaria elimination efforts and are excited about recent advances in genomic research that make genetic modification a realistic option for malaria control in particular. As with other approaches to controlling or eventually eradicating the disease, this won’t be a complete solution. But it’s got the potential to strengthen the global fight against malaria.</p>
<h2>Genetic modification for malaria control</h2>
<p>Mosquitoes can be genetically modified through two different technologies. The first method, <a href="https://surface.syr.edu/cgi/viewcontent.cgi?article=1142&context=eli">paratransgenesis</a>, involves infecting mosquitoes with bacteria that prevent them from transmitting malaria. This doesn’t harm the mosquito. It is important not to eliminate or harm mosquitoes because they pollinate many plants and are <a href="https://www.reconnectwithnature.org/news-events/the-buzz/world-without-mosquitoes-not-as-easy-as-it-seems/">food</a> for animals like bats, birds and reptiles.</p>
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Read more:
<a href="https://theconversation.com/curious-kids-what-would-happen-if-all-the-mosquitoes-in-the-world-disappeared-175528">Curious Kids: What would happen if all the mosquitoes in the world disappeared?</a>
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<p>Scientists are excited about this method following the <a href="https://www.ft.com/content/c4db7776-e776-4717-bf9d-7792d5ff0ad0">recent discovery</a> of a bacterium that occurs naturally in mosquitoes’ guts and appears to prevent the malaria parasite from developing inside the mosquito.</p>
<p>The second method involves genetically modifying the mosquitoes themselves. This approach centres on <a href="https://www.synthego.com/blog/gene-drive-crispr">gene drives</a>: genetic systems that ensure genes of interest are inherited by all offspring in every generation. There are two types of gene drive. One aims to reduce the vector population size and is known as population suppression. The other aims to prevent the mosquito from transmitting malaria; it is known as population modification.</p>
<p>Gene drives focusing on population suppression have <a href="https://www.isaaa.org/kc/cropbiotechupdate/gdn/article/default.asp?ID=19494">shown great promise in laboratory studies</a>. They’ve yet to be tested in the field, though. </p>
<p>Population modification potentially has fewer environmental effects and is less prone to developing mutations. But it has proved more challenging to achieve and has not progressed as far as the suppression approach.</p>
<h2>Addressing scepticism</h2>
<p>It will be a while before this technology is routinely used by malaria control programmes. But preparation is under way. </p>
<p>Over the past decade, malaria control programmes have expressed a willingness to use genetic modification if and when such techniques are shown to be safe and acceptable to the affected communities. This has prompted the WHO <a href="https://www.who.int/news/item/19-05-2021-who-issues-new-guidance-for-research-on-genetically-modified-mosquitoes-to-fight-malaria-and-other-vector-borne-diseases">to provide guidance</a> on the use of genetically modified mosquitoes to control malaria and other vector-borne diseases.</p>
<p>In its guidance, the WHO acknowledges how crucial community engagement will be to the success of any future gene drive interventions.</p>
<p>This is important in an environment where there is <a href="https://theconversation.com/the-reasons-for-science-skepticism-can-be-complex-and-founded-on-real-concerns-171000">marked scepticism</a> about science, and particularly about genetically modified organisms (GMOs). In 2003, community resistance resulted in the rejection of genetically modified golden rice <a href="https://www.un.org/africarenewal/magazine/february-2003/controversy-rages-over-gm-food-aid#:%7E:text=Many%20Zambians%20believe%20that%20GMOs,in%20people%20with%20poor%20health.">in Zambia</a>, despite the country experiencing a pronounced food shortage. </p>
<p>More recently, there was backlash against the COVID-19 mRNA vaccines, which some people <a href="https://www.health.gov.au/our-work/covid-19-vaccines/is-it-true/is-it-true-can-covid-19-vaccines-alter-my-dna">suspected</a> of being capable of altering human DNA (it isn’t). </p>
<p>It is critical that the concerns of communities where genetically modified mosquitoes are to be released are addressed prior to any release. This will help promote acceptance and understanding of the new technology.</p>
<h2>Considerable investment</h2>
<p>However, community acceptance is not the only challenge. There is an urgent need for research on the relevant local malaria mosquito species so that the required genetically modified mosquitoes can be developed. Once the genetically modified lines are established, impact in the field must be demonstrated and systems established to ensure suitable numbers of mosquitoes can be reared and safely transported to the intervention sites. </p>
<p>All this requires considerable human resources and funding, suggesting that it will be some time before gene drive systems have real-world impact on malaria transmission.</p>
<p>Still, as the globe marks <a href="https://nationaltoday.com/world-mosquito-day/">World Mosquito Day</a> on 20 August, in honour of Sir Ronald Ross’s discovery almost 130 years ago, we believe there is reason for optimism: novel technologies like genetic modification have the potential to play a major role in the fight against malaria.</p><img src="https://counter.theconversation.com/content/211703/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shüné Oliver receives funding from the National Research Foundation of South Africa, the South African Medical Research Council and the Female Academic Leadership Fellowship of the University of the Witwatersrand. She is affiliated to the Wits Research Institute for Malaria at the University of the Witwatersrand. </span></em></p><p class="fine-print"><em><span>Jaishree Raman receives funding from Bill and Melinda Gates Foundation, Global Fund, CHAI, South African Medical Research Council, South African Research Trust, National Research Foundation and the National Institute for Communicable Diseases. She is affiliated with the Wits Research Institute for Malaria, University of Witwatersrand and UP Institute for Sustainable Malaria Control, University of Pretoria.</span></em></p>Methods that don’t rely on insecticides are needed to bolster the fight against mosquito-borne diseases.Shüné Oliver, Medical scientist, National Institute for Communicable DiseasesJaishree Raman, Principal Medical Scientist and Head of Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2087262023-06-30T12:40:44Z2023-06-30T12:40:44ZLocally transmitted malaria in the US could be a harbinger of rising disease risk in a warming climate – 5 questions answered<figure><img src="https://images.theconversation.com/files/534730/original/file-20230629-15-k04fb9.jpg?ixlib=rb-1.1.0&rect=8%2C17%2C5879%2C3910&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some evidence suggests that malaria mosquitoes are becoming resistant to insecticides.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/anopheles-maculipennis-royalty-free-image/522212584?phrase=malaria&adppopup=true">Paul Starosta/Stone via Getty Images</a></span></figcaption></figure><p><em>The Centers for Disease Control and Prevention reported on June 26, 2023, that five cases of <a href="https://emergency.cdc.gov/han/2023/han00494.asp">locally transmitted malaria had been identified</a> – four in Florida and one in Texas – since May 2023. These are the first cases of locally acquired mosquito-borne malaria in the U.S. since 2003.</em> </p>
<p><em>The Conversation spoke with <a href="https://stempel.fiu.edu/faculty-staff/profiles/chowdhury-rajiv.html">Dr. Rajiv Chowdhury</a>, a <a href="https://scholar.google.co.uk/citations?user=lmhOm1sAAAAJ&hl=en">global health expert</a> from Florida International University, about the significance of these cases and why they’re appearing now.</em></p>
<h2>1. What is malaria and how did these people become infected?</h2>
<p>Malaria is a serious and sometimes life-threatening disease caused by the bite of a female mosquito from the genus <em>Anopheles</em>, the vector <a href="https://www.niaid.nih.gov/diseases-conditions/malaria-parasite#">that transmits malaria</a>. </p>
<p>The most common symptoms are fever, chills, headaches, muscle aches and fatigue. These symptoms typically occur from 10 to 15 days after people are infected with the parasite. However, if untreated, more <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">severe symptoms</a> may appear that include impaired consciousness, difficulty breathing, convulsions, abnormal bleeding and more, which can ultimately lead to death.</p>
<p>The five cases in Florida and Texas were caused by the <em>Plasmodium vivax</em> parasite, which is the most common malaria-causing parasite strain <a href="https://www.ncbi.nlm.nih.gov/books/NBK538333/">outside of the African continent</a>. All are believed to be locally acquired, which means they were not connected to any international travel. In addition, there is no evidence to suggest that the cases in the two states are related. <em>Plasmodium vivax</em> is the most globally widespread of all <em>Plasmodium</em> strains and can cause severe, often fatal, infections. </p>
<p>All five patients have <a href="https://www.floridahealth.gov/newsroom/2023/06/20230626-mosquito-borne-illnesses.pr.html">reportedly recovered</a>, and surveillance for additional cases is ongoing.</p>
<h2>2. Why might these cases be surfacing now?</h2>
<p>There could be several factors driving the emergence of locally acquired malaria.</p>
<p>For one, climate change is <a href="https://doi.org/10.1016/S0140-6736(17)31119-4">causing a shift in weather patterns</a>, some of which can worsen malaria conditions. A higher average surface temperature from global warming could lead to higher mosquito migration in areas that were <a href="https://doi.org/10.1016/S2542-5196(22)00039-0">previously uninhabitable by <em>Anopheles</em> mosquitoes</a>.</p>
<p>These higher temperatures could also <a href="https://www.un.org/en/chronicle/article/climate-change-and-malaria-complex-relationship">enhance the growth rate and transmissibility of the parasites</a> responsible for malaria. These include Plasmodium parasite variants such as <em>vivax</em>, <em>knowlesi</em> and <em>falciparum</em>.</p>
<p>The effects of climate change can also lead to <a href="https://doi.org/10.1186/s12936-021-03718-x">higher rainfall and sea level rise</a> in many places – both of which can result in more areas or open spaces with stagnant water that typically serve as effective breeding grounds for mosquitoes. </p>
<p>Given these changes in local conditions, more cases could occur in populations that were previously <a href="https://doi.org/10.1073/pnas.1302089111">“immunologically naïve” to malaria</a>. In other words, since these people have never been exposed to it, their immune systems are ill-equipped to fight it.</p>
<p>Furthermore, when people travel to countries or areas where climate-driven malaria cases are on the rise, there is a greater possibility of bringing those infections back to the U.S., where local mosquitoes could be exposed to the parasite in an infected person’s blood. </p>
<p>Lastly, due to misuse and overuse of common antimalarial medications, <a href="https://doi.org/10.1016/S2666-5247(21)00249-4">such as artemisinin</a>, antimicrobial resistance has become <a href="https://www.cdc.gov/malaria/malaria_worldwide/reduction/drug_resistance.html">a major problem in many regions</a> of the world. This drives up the number of drug-resistant cases, the severity of the illness and the possibility of larger outbreaks.</p>
<p>This is further complicated by emerging <a href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022">resistance to insecticides</a> among <em>Anopheles</em> mosquitoes.</p>
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<figcaption><span class="caption">When traveling overseas this summer, here’s what to remember.</span></figcaption>
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<h2>3. How can people help prevent malaria transmission?</h2>
<p>The CDC and the Florida Department of Health are urging people to protect themselves by using bug spray, avoiding areas where mosquitoes congregate and covering exposed skin.</p>
<p>Precautions also include what’s known as “<a href="https://www.floridahealth.gov/newsroom/2023/06/20230626-mosquito-borne-illnesses.pr.html">drain and cover</a>” – in other words, draining standing water to prevent mosquitoes from multiplying and using screens to prevent mosquitoes from entering through doors and windows. Health departments also note that it’s important to drain or discard containers that can collect rainwater, such as flower pots, old tires and buckets. </p>
<h2>4. What are the available malaria treatments?</h2>
<p>There are several medicines used to prevent and treat malaria. The choice of medication typically depends on the type of malaria, whether a malaria parasite is resistant to a medicine, the weight or age of the person infected with malaria and whether the person is pregnant. </p>
<p>Most malaria medicines are taken in pill form. The most common include combination therapy medicines that include a class of <a href="https://doi.org/10.1016%2Fj.tips.2008.07.004">semi-synthetic drugs called artemisinins</a>. These kill malaria parasites by damaging their proteins and are usually the most effective treatment against malaria. <a href="https://medlineplus.gov/druginfo/meds/a682318.html#">Chloroquine phosphate</a>, a medicine that has been used for decades to prevent and treat malaria, is now recommended for treatment of infection with <em>Plasmodium vivax</em>, but only in places where the parasite is still sensitive to this medicine. Lastly, there’s <a href="https://medlineplus.gov/druginfo/meds/a607037.html#">primaquine</a>, a class of antimalarial drugs typically added to complement another treatment to prevent any relapse of infection. </p>
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<h2>5. Are vaccines against malaria available?</h2>
<p>Nearly half of the <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">global population is currently at risk</a> of malaria, with almost 250 million cases and 620,000 deaths worldwide, mostly affecting children. Therefore, in October 2021, the World Health Organization began <a href="https://theconversation.com/who-approved-a-malaria-vaccine-for-children-a-global-health-expert-explains-why-that-is-a-big-deal-169501">recommending the widespread use</a> of a malaria vaccine known as RTS,S/ASOI for children who live in moderate- to high-risk areas.</p>
<p>This is the first-ever <a href="https://www.who.int/news/item/06-10-2021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk">vaccine for a human parasitic infection</a>. Trials show that the vaccine can <a href="https://doi.org/10.1016/S0140-6736(15)60721-8">significantly reduce malaria</a>, including severe malaria, among young children. </p>
<p>A group of scientists from the U.K. reported a <a href="https://doi.org/10.1016/S1473-3099(22)00442-X">modified version of this vaccine</a>, called R21, in September 2022. The early-phase clinical trial reported that the new vaccine is 80% effective at preventing disease in young children. However, real-world trials for this new candidate vaccine are still ongoing. </p>
<p>Other <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/biontech-initiates-clinical-trial-mrna-based-malaria-vaccine-candidate-2022-12-23/#">vaccine candidates</a> are currently being developed by BioNTech, the company behind the Pfizer/BioNTech mRNA COVID-19 vaccine, and through <a href="https://www.forbes.com/sites/roberthart/2023/06/05/novavax-partners-with-gates-foundation-offshoot-in-efforts-to-develop-malaria-and-tb-shots/?sh=2354fd313d51">joint efforts</a> between Novavax and the Bill & Melinda Gates Medical Research Institute.</p>
<p>While new malaria vaccines will be a major boost for curbing malaria worldwide, it will be critical for health departments to continue emphasizing other preventive strategies, especially in newly affected areas like Florida and Texas.</p><img src="https://counter.theconversation.com/content/208726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rajiv Chowdhury does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>After recent cases in Florida and Texas, authorities are advising the public to drain standing water sources to keep mosquitoes from multiplying.Rajiv Chowdhury, Professor of Global Health, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2041482023-04-24T12:04:29Z2023-04-24T12:04:29ZNigeria has Africa’s highest malaria death rate - progress is being made, but it’s not enough<figure><img src="https://images.theconversation.com/files/522576/original/file-20230424-1209-sj0dw5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lagos residents use art to draw attention to the gaps in the prevention and treatment of malaria. According to UNICEF, over 1,000 children under the age of 5 catch malaria every day. </span> <span class="attribution"><span class="source">Pius Utomi Ekpei/AFP via Getty Images</span></span></figcaption></figure><p><em><a href="https://www.who.int/news-room/fact-sheets/detail/malaria">Malaria</a> is a major public health problem and can be life-threatening. The disease, mostly found in tropical countries, is transmitted to humans by the female Anopheles mosquito. Nearly half of the world’s population is at risk of the disease. <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">In 2021</a>, for instance, around 247 million cases of malaria were reported and <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">about 619,000</a> people died. <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">Four African countries</a> accounted for just over half of all malaria deaths worldwide: Nigeria (31.3%), the Democratic Republic of the Congo (12.6%), Tanzania (4.1%) and Niger (3.9%).</em></p>
<p><em><a href="https://msh.org/people/dr-olugbenga-a-mokuolu/">Professor Olugbenga A. Mokuolu </a>currently oversees all malaria work in Nigeria for Management Sciences for Health, a global health advisory organisation. He’s also the former technical director to the National Malaria Elimination Programme in Nigeria. Molecular parasitology Professor, Segun Isaac Oyedeji, spoke to him about Nigeria’s malaria burden.</em></p>
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<p><strong>Segun Oyedeji:</strong> Nigeria has a high malaria burden. How did it get here?</p>
<p><strong>Olugbenga Mokuolu:</strong> It’s a combination of many things.</p>
<p>The existence of malaria anywhere is an interaction between the environment and the organism responsible for the disease, the mosquito. When you look at an environment, you’re looking at a variety of natural factors – such as temperature, humidity and rainfall – and man-made factors, such as drainage systems. This is because certain conditions allow mosquitoes to thrive – specifically moisture-rich environments. Mosquitoes <a href="https://theconversation.com/heavy-rains-put-kenya-at-risk-of-mosquito-borne-diseases-130076">breed by laying</a> their eggs in stagnant water. </p>
<p>Nigeria’s environment is a favourable one in which mosquitoes – the malaria vector – can thrive. </p>
<p>In terms of environmental management, Nigeria leaves a lot to be desired. The country has open refuse sites, blocked drainage systems, and – because people lack piped water – they store water at home in containers. These all provide <a href="https://www.cdc.gov/mosquitoes/about/where-mosquitoes-live.html">ideal sites</a> for mosquitoes to breed.</p>
<p>In terms of humidity, Nigeria has <a href="https://www.intechopen.com/chapters/65196">vegetation</a> that favours the reproductive stages of the parasite in the mosquito. <a href="https://pubmed.ncbi.nlm.nih.gov/14596287/#:%7E:text=The%20primary%20effect%20of%20increasing,at%20extraordinarily%20low%20vector%20densities.">Altitude also plays a role</a>. And, in most of Nigeria, the altitude allows the mosquito to fly around without much difficulty. Only the <a href="https://www.nigeriagalleria.com/Nigeria/States_Nigeria/Taraba/Mambilla-Plateau-Taraba.html">Mambilla Plateau</a> is considered relatively malaria free in Nigeria. It has an altitude that is above 5000 feet which makes it difficult for mosquitoes to inhabit. </p>
<p>In addition to this, Nigeria has a large population which makes malaria transmission much easier. Large populations mean more people tend to live closer together, which makes it easier for the mosquito vector to quickly find a contact for transmission of the malaria parasite. In addition, a large population puts more pressure on sanitation services, leading to more mosquito breeding sites. </p>
<p>That’s not to say no progress has been made. The country’s interventions have not been a failure altogether. My organisation is supporting Nigeria to provide preventive chemotherapy for malaria. We have reached over 25 million children under five in our intervention cycles. This is shown to have significant contribution to reduction in mortality. But we are not yet where we are supposed to be.</p>
<p><strong>Segun Oyedeji:</strong> Children are disproportionately affected. What can be done?</p>
<p><strong>Olugbenga Mokuolu:</strong> The Nigerian government and its partners have singled out children as the focus of most interventions. In addition, we need health system strengthening to address the gaps in access particularly at communities. </p>
<p>The Nigerian National Agency for Food and Drug Administration And Control <a href="https://www.nafdac.gov.ng/press-briefing-by-prof-mojisola-christianah-adeyeye-director-general-national-agency-for-food-and-drug-administration-and-control-nafdac-on-the-regulatory-approval-of-r21-malaria-vaccine-by-nafdac/">recently approved</a> the R21 malaria vaccine for use. </p>
<p>Hopefully when the R21 vaccine becomes available it will reduce new cases or the impact of cases. It is unclear when the vaccine may be rolled out in Nigeria. </p>
<p>A recent study shows that the <a href="https://www.ox.ac.uk/news/2023-04-13-r21matrix-m-malaria-vaccine-developed-university-oxford-receives-regulatory#:%7E:text=This%20followed%202021%20results%20from,and%20a%20reassuring%20safety%20profile.">R21 vaccine has some efficacy</a>. This vaccines has shown most effective when administered to children from five months to 36 months old. It is 77% effective in preventing infection and reduces the occurrence of severe malaria. Reducing the frequency of severe malaria reduces the burden of malaria mortality by extension. </p>
<p>The vaccines won’t be used on their own. They will be used as adjuncts to existing tools for fighting malaria such as preventative treatment and the distribution of bed nets.</p>
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Read more:
<a href="https://theconversation.com/what-nigeria-must-do-to-eliminate-malaria-three-researchers-offer-insights-159460">What Nigeria must do to eliminate malaria: three researchers offer insights</a>
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<p><strong>Segun Oyedeji:</strong> How can Nigeria reduce its malaria burden? </p>
<p><strong>Olugbenga Mokuolu:</strong> New cases of malaria can only be curbed by environmental measures, including the use of insecticide nets and personal protection. I know the vaccines aren’t 100% effective, but surely they will offer additional prevention. </p>
<p>But Nigeria needs to step up its game. The current <a href="https://drive.google.com/file/d/10da1qdiUbqxcZZHGa7uZxStnyFn9nFo-/view?pli=1">National Malaria Strategic Plan 2021 to 2025</a> is based on a well researched model. It is no longer business as usual. The plan clearly shows that if we don’t do more, malaria will keep rising. </p>
<p>But we are actually doing a lot.</p>
<p>Take the bed nets. These are being distributed on an almost regular basis to eligible states. Even COVID-19 didn’t stop the distribution. Now because of the size of Nigeria’s population, bed nets are distributed in what we call mass roll out campaigns with each state doing its own campaign. The improvement in malaria control that we have seen the last five to seven years is based on the intensity of interventions in two thirds of our states. </p>
<p>But Nigeria has gone further to almost be a global example, in how to implement <a href="https://www.who.int/teams/global-malaria-programme/prevention/preventive-chemotherapies">preventive chemotherapy</a>. We have 21 states out of 36 states where we reached over 25 million under five children in each cycle of intervention. We have four cycles in the year and this has contributed to reduction in mortality. </p>
<p>But we could do more. </p>
<p>Malaria isn’t going to be reduced significantly unless Nigeria intensifies development. Development plays a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856737/">major role</a> in reducing the burden. </p>
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Read more:
<a href="https://theconversation.com/ending-malaria-in-africa-needs-to-focus-on-poverty-quick-fixes-wont-cut-it-169205">Ending malaria in Africa needs to focus on poverty: quick fixes won't cut it</a>
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<p>Also, infusion of funds and not just from the government. There is also public-private partnership for drug manufacturers. The government should give them a protected market and negotiate good prices. Let the manufacturers take over distribution using their own market principles in a manner that will be affordable to many people.</p>
<p>We need to look at new initiatives and also position ourselves in the vaccine game with respect to malaria. </p>
<p><strong>Segun Oyedeji:</strong> How can the international community – donors and aid agencies – best support Nigeria? </p>
<p><strong>Olugbenga Mokuolu:</strong> International partners are supporting the country in many ways. Largely the support is in funding and technical areas. Going forward, countries like Nigeria will need stronger support for consolidating current gains, new tools, health system strengthening, scaling up access to vaccine and local manufacturing or production of malaria intervention commodities.</p><img src="https://counter.theconversation.com/content/204148/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Segun Isaac Oyedeji receives funding from Deutscher Akademischer Austausch Dienst (DAAD), Tertiary Education Trust Fund (TETFUND).</span></em></p>Nigeria must do more to reduce its high malaria burden.Segun Isaac Oyedeji, Professor in Molecular Parasitology and Genetics, Federal University, Oye EkitiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2041972023-04-24T07:40:10Z2023-04-24T07:40:10ZHope is on the horizon for a malaria-free Africa<figure><img src="https://images.theconversation.com/files/522551/original/file-20230424-22-80rbgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A factory producing insecticidal bed nets in Arusha, Tanzania.
</span> <span class="attribution"><span class="source">Photo by Charles Ommanney/Getty Images</span></span></figcaption></figure><p>Sub-Saharan Africa is <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">disproportionally affected by malaria</a>. The region accounts for 95% of the world’s malaria cases. The disease kills an African child every <a href="https://data.unicef.org/topic/child-health/malaria/">60 seconds</a>. </p>
<p>These figures are alarming. But malaria is preventable and treatable. </p>
<p>The progress made between 2000 and 2015 is proof of what can be achieved. Support from global donors helped <a href="https://apps.who.int/iris/bitstream/handle/10665/205224/WHO_HTM_GMP_2016.2_eng.pdf#page=9">drive down malaria deaths</a> among children under five from 723,000 to 306,000. Most of the deaths prevented were in sub-Saharan Africa. Fifty-five of the 106 malaria-endemic countries showed a 75% decrease in new malaria cases by <a href="https://www.who.int/news/item/09-12-2015-new-report-signals-country-progress-in-the-path-to-malaria-elimination">2015 compared to 2000</a>. </p>
<p>But <a href="https://reliefweb.int/report/world/world-malaria-report-2017">in 2016</a>, the global malaria response plateaued. In some regions it even backtracked. Malaria <a href="https://www.devex.com/news/world-is-badly-off-track-in-reaching-malaria-goals-102222">cases and deaths increased</a> as national malaria control programmes competed with other health challenges. </p>
<p>The World Health Organization (WHO) and other partners issued urgent calls to address the challenges national programmes were facing. But the gap in funding and technical capacity widened. Malaria control efforts in Africa remained woefully <a href="https://www.afro.who.int/news/getting-malaria-prevention-back-track#:%7E:text=We%20are%20off%20the%20track,indicating%20that%20we%20are%20stagnating">off-track</a> to meeting 2030 elimination targets. </p>
<p>And then the COVID-19 pandemic hit. </p>
<p>At the start of the pandemic, there were <a href="https://www.reuters.com/article/us-africa-malaria-idUSKCN22529Q">dire warnings</a> of catastrophic disruptions to routine malaria services. These were expected to lead to a doubling of malaria deaths in Africa. </p>
<p>There were disruptions. But national malaria control programmes have shown impressive resilience over the past three years. Innovative actions saw malaria deaths increase by only <a href="https://data.unicef.org/topic/child-health/malaria/">10%</a> between 2019 and 2020. Malaria deaths didn’t double, and have <a href="https://www.who.int/news/item/08-12-2022-despite-continued-impact-of-covid-19--malaria-cases-and-deaths-remained-stable-in-2021">remained stable in 2021</a>.</p>
<p>Now, the battle to eliminate and eventually eradicate malaria has become even more challenging. The challenges include the impact of climate change on the distribution of malaria-carrying mosquitoes; the invasion and rapid spread of new mosquito species; as well as emerging drug-resistant malaria parasites and insecticide-resistant mosquitoes. </p>
<p>However, there is hope on the horizon. After decades of intense research, two new malaria vaccines have come to market. And researchers are developing new treatments and experimenting with different drug combinations. It may not happen by 2030, but malaria can be <a href="https://healthpolicy-watch.news/malaria-eradication-feasible-by-2050-says-new-lancet-commission-report/">eradicated</a>. </p>
<h2>History</h2>
<p>In 2000, the United Nations launched the <a href="https://research.un.org/en/docs/dev/2000-2015">millennium development goals</a>. One of the goals was to <a href="https://documents-dds-ny.un.org/doc/UNDOC/GEN/N00/559/51/PDF/N0055951.pdf?OpenElement">reduce the malaria burden</a> by 75% by 2015. This catalysed significant investments, particularly in sub-Saharan Africa. Between 2000 and 2015, international donor funding primarily from the <a href="https://www.theglobalfund.org/en/">Global Fund to Fight AIDS, Tuberculosis and Malaria</a> and the American government-led <a href="https://www.pmi.gov/">President’s Malaria Initiative</a>, enabled national malaria control programmes in Africa to replace failing interventions with more effective ones. </p>
<p>By <a href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2016">2015</a>, over 150 million insecticide-treated bednets; 179 million malaria rapid diagnostic tests; and 153 million doses of the malaria treatment recommended by the WHO – artemisinin-based combination therapies (ACTs) – had been distributed across Africa. </p>
<p>Encouraged by the progress in rolling back malaria, the WHO launched the <a href="https://www.who.int/publications/i/item/9789241564991">Global Technical Strategy for Malaria</a>. This strategy provided malaria-endemic countries with a roadmap for reducing malaria transmission. The ultimate aim was to have a world free of malaria by 2030. </p>
<p>Unfortunately, the release of this strategy coincided with a levelling off in domestic and international funding, which led to an uptick in malaria cases.</p>
<p>In <a href="https://cdn.who.int/media/docs/default-source/Documents/world-malaria-report-2017.pdf?sfvrsn=8b7b573a_0">2016</a>, there were 216 million cases – five million more than in 2015. Ninety per cent of the new cases were in Africa where funding had dropped to less than <a href="https://reliefweb.int/report/world/world-malaria-report-2017">42%</a> of what the continent required for effective malaria control. </p>
<h2>Setbacks</h2>
<p>Now the global malaria response faces new challenges. </p>
<p>Climate change <a href="https://www.news-medical.net/health/The-Effect-of-Climate-Change-on-Malaria.aspx">experts predict</a> that as the Earth warms up, malaria will spread into malaria-free areas. The malaria mosquito and parasite will develop faster. And that malaria transmission rates in areas where the disease is currently will increase. In addition, environmental changes linked to human activities, such as deforestation, are also likely to change the distribution of mosquitoes and the diseases they carry.</p>
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Read more:
<a href="https://theconversation.com/how-higher-temperatures-and-pollution-are-affecting-mosquitoes-114768">How higher temperatures and pollution are affecting mosquitoes</a>
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<p>The recent <a href="https://reliefweb.int/report/world/vector-alert-anopheles-stephensi-invasion-and-spread-africa-and-sri-lanka">invasion and rapid spread</a> of the Asian malaria vector, <em>Anopheles stephensi</em>, through the Horn of Africa and as far west as Nigeria, may be an example of this. It has been identified as a threat to malaria elimination efforts in Africa. This mosquito species is <a href="http://www.mesamalaria.org/mesa-track/deep-dives/anopheles-stephensi">extremely difficult to control</a>. It thrives in urban areas, bites both in and outdoors, feeds on animals and humans, and is resistant to several insecticide classes. Acutely aware of the threat that this mosquito poses to malaria control in Africa, the WHO released an <a href="https://www.who.int/news/item/29-09-2022-who-launches-new-initiative-to-stop-the-spread-of-invasive-malaria-vector-in-africa">initiative</a> to slow the spread of this vector into the rest of Africa.</p>
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Read more:
<a href="https://theconversation.com/a-new-invasive-mosquito-has-been-found-in-kenya-what-this-means-for-malaria-control-200753">A new invasive mosquito has been found in Kenya – what this means for malaria control</a>
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<p>Not to be outdone, the malaria parasite has also thrown a few curve balls into the mix. <em>Plasmodium falciparum</em> is the deadliest and most prevalent human malaria parasite in Africa. It has <a href="https://apps.who.int/iris/bitstream/handle/10665/325528/WHO-CDS-GMP-2019.02-eng.pdf">mutated</a> and can go undetected by the most widely used point-of-care diagnostic tool in rural malaria endemic regions. This leaves malaria-infected individuals at risk of developing severe illness, and still capable of transmitting malaria. In addition, African malaria parasites from Eritrea, Rwanda and Uganda have become resistant to the artemisinin part of ACTs. ACTs are the only class of effective antimalarial currently available. The WHO has developed a <a href="https://www.who.int/news/item/18-11-2022-tackling-emerging-antimalarial-drug-resistance-in-africa">strategy</a> for tackling emerging resistance in Africa.</p>
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Read more:
<a href="https://theconversation.com/some-malaria-parasites-are-evading-detection-tests-causing-an-urgent-threat-to-public-health-177258">Some malaria parasites are evading detection tests, causing an urgent threat to public health</a>
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<h2>Way ahead</h2>
<p>In 2021, the WHO took the bold step of approving the use of the RTS,S malaria vaccine in high-burden countries, despite its very modest efficacy of less than <a href="https://www.malariavaccine.org/malaria-and-vaccines/rtss">40%</a>. </p>
<p>A newer version of the RTS,S vaccine, the R21 vaccine produced by Oxford University’s Jenner Institute, has shown much high efficacy in a Phase III trial. This has prompted <a href="https://www.theguardian.com/global-development/2023/apr/13/ghana-is-first-country-to-approve-oxford-r21-malaria-vaccine">Ghana</a> and <a href="https://punchng.com/breaking-nigeria-becomes-second-country-to-approve-r21-malaria-vaccine/">Nigeria</a> to approve its use this month without pre-approval from the WHO.</p>
<p>Researchers are developing newer, more effective <a href="https://www.radboudumc.nl/en/news-items/2022/new-malaria-drug-is-ready-for-testing-in-humans">antimalarials</a>. Others are investigating using <a href="https://www.eurekalert.org/news-releases/521924">different combinations</a> of existing drug and <a href="https://www.nih.gov/news-events/nih-research-matters/antibody-treatment-protects-adults-against-malaria">antibodies</a> to effectively treat malaria. </p>
<p>Newer, more effective insecticide-treated nets are being <a href="https://reliefweb.int/report/world/who-publishes-recommendations-two-new-types-insecticide-treated-nets">rolled out</a>. And <a href="https://www.who.int/initiatives/genomic-surveillance-strategy">genomic surveillance</a> is a new tool in the malaria elimination toolbox to assist with evidence-based decision-making.</p><img src="https://counter.theconversation.com/content/204197/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaishree Raman is affiliated with the National Institute for Communicable Diseases, the Wits Research Institute for Malaria and UP Institute for Sustainable Malaria Control. She receives funding from the Bill and Melinda Gates Foundation, the Global Fund, Clinton Health Access Initiative, the South African Medical Research Council, the South African Research Trust, the National Research Foundation and the National Institute for Communicable Diseases.</span></em></p>There have been disruptions. But national malaria control programmes have shown impressive resilience.Jaishree Raman, Principal Medical Scientist and Head of Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2015692023-04-18T20:01:07Z2023-04-18T20:01:07ZDiseases gave us the rise of Christianity, the end of the Aztecs and public sanitation. How might future plagues change human history?<figure><img src="https://images.theconversation.com/files/517613/original/file-20230327-27-ualse4.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4439%2C3183&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Elena Mozhvilo/Unsplash</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>“Every once in a while a book lands on your desk that changes the way you perceive the world you live in, a book that fundamentally challenges your understanding of human history.” So began the blurb that came with this book. Aha! I thought. The usual advertising hyperbole, a gross exaggeration. </p>
<p>Yet <a href="https://www.penguin.com.au/books/pathogenesis-9781911709053">Pathogenesis</a> <em>did</em> challenge much of my understanding of world history. Who knew that if it wasn’t for an Ebola-like pandemic in the 2nd century CE, Christianity would never have become a world religion? Or that if it weren’t for retroviruses, women would be laying eggs rather than having live births? (According to the book’s author, a retrovirus inserted DNA into our ancestor’s genome that caused the placenta to develop.)</p>
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<p><em>Book review: Pathogenesis: How germs made history – by Jonathan Kennedy (Torva)</em></p>
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<p>However, this is not another book of Amazing Facts: it is a work of scholarship, with nearly 700 references and notes. At the same time, it is very readable, and even amusing at times. </p>
<p>Many books have been written about the impact of disease on civilisation. I have even written my own modest <a href="https://medium.com/@adrian.esterman/infectious-diseases-and-their-impact-on-civilisation-4eb8ac72cc5b">essay</a> on the topic. However,
Pathogenesis delves deeply into the social history of the world. </p>
<p>Jonathan Kennedy has a PhD in sociology from the University of Cambridge, and his sociological bent comes through strongly. In eight chapters, and some 350 pages, Kennedy takes us on a whirlwind tour of social history, describing how infectious diseases have shaped humanity at every stage. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/viruses-are-both-the-villains-and-heroes-of-life-as-we-know-it-169131">Viruses are both the villains and heroes of life as we know it</a>
</strong>
</em>
</p>
<hr>
<h2>‘It’s a bacterial world’</h2>
<p>Kennedy starts by describing the three great branches of living organisms, <a href="https://theconversation.com/from-peaceful-coexistence-to-potential-peril-the-bacteria-that-live-in-and-on-us-104110">bacteria</a>, <a href="https://microbiologysociety.org/why-microbiology-matters/what-is-microbiology/archaea.html">archaea</a>, and <a href="https://www.britannica.com/science/eukaryote">eukaryotes</a> – it is the latter that contains all complex life forms, including humans. However, fewer than 0.001% of all species are eukaryotes. </p>
<p>Bacteria, on the other hand, are the dominant life form on this planet. As Kennedy puts it, “it’s a bacterial world, and we’re just squatting here”. </p>
<p>Our own species, <em><a href="https://theconversation.com/rethinking-homo-sapiens-the-story-of-our-origins-gets-dizzyingly-complicated-99760">Homo sapiens</a></em>, arose some 315,000 years ago, living for the most part in Africa. At the same time, human species such as Neanderthals and <a href="https://theconversation.com/dna-from-elusive-human-relatives-the-denisovans-has-left-a-curious-mark-on-modern-people-in-new-guinea-196113">Denisovans</a> spread out into Europe. However, about 50,000 years ago, <em>Homo sapiens</em> burst out of Africa and spread across the world, while all other human species simply vanished. There are many <a href="https://www.scientificamerican.com/article/how-homo-sapiens-became-the-ultimate-invasive-species/">theories</a> as to why and how this occurred – for example, perhaps <em>Homo sapiens</em> were just smarter. </p>
<p>However, Kennedy proposes his own theory. Because <em>Homo sapiens</em> lived primarily in Africa, they were exposed to many pathogens, and eventually acquired genetic changes that gave them some protection. The exodus out of Africa exposed other species to these pathogens, causing their demise. </p>
<p>He describes the <a href="https://theconversation.com/who-were-the-mysterious-neolithic-people-that-enabled-the-rise-of-ancient-egypt-heres-what-weve-learned-on-our-digs-121070">Neolithic</a> revolution, which took place about 12,000 years ago and which saw the change from hunter-gatherers to farmers. Because of their nomadic existence in small groups, hunter-gatherers tended to be relatively healthy, with an average lifespan of 72 - better than the average lifespan in some countries today! </p>
<p>It has always been assumed that this revolution was a good thing, bringing better nutrition and more leisure time. However, in Kennedy’s view, the Neolithic revolution led to the emergence of despotism, inequality, poverty and backbreaking work. He describes how settlement and the farming of domestic animals led to the emergence of zoonotic diseases – that is, <a href="https://theconversation.com/preventing-future-pandemics-starts-with-recognizing-links-between-human-and-animal-health-167617">diseases spread by animals</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517617/original/file-20230327-24-pz4erz.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Settlement and the farming of domestic animals led to the emergence of diseases spread by animals.</span>
<span class="attribution"><span class="source">kallerna/Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/disease-evolution-our-long-history-of-fighting-viruses-54569">Disease evolution: our long history of fighting viruses</a>
</strong>
</em>
</p>
<hr>
<h2>Plagues and social upheavals</h2>
<p>In a chapter on ancient plagues, Kennedy quotes from Monty Python’s <a href="https://theconversation.com/life-of-brian-at-40-an-assertion-of-individual-freedom-that-still-resonates-114743">The Life of Brian</a>: </p>
<blockquote>
<p>All right, but apart from the sanitation, the medicine, education, wine, public order, irrigation, roads, a fresh water system, and public health, what have the Romans ever done for us?</p>
</blockquote>
<p>He points out that Roman cities were, in fact, “filthy, stinking and disease-ridden”, and goes on to describe the great plagues <a href="https://theconversation.com/how-3-prior-pandemics-triggered-massive-societal-shifts-146467">that weakened the Roman Empire</a>. The first was the Antonine Plague, possibly caused by smallpox. This was followed some 70 years later by the Plague of Cyprian from AD 249-262, which led to the splitting of the Roman Empire and the rise of Christianity. </p>
<p>Kennedy completes this chapter with a description of the Plague of Justinian, caused by bubonic plague. The massive deaths caused by this epidemic led to the demise of the Roman Empire, and the Muslim conquest of the Middle East. </p>
<p>In the period 1346–53, the <a href="https://theconversation.com/did-the-black-death-give-birth-to-modern-plagues-3820">Black Death</a> tore through North Africa and Europe, killing an <a href="https://en.wikipedia.org/wiki/Black_Death">estimated</a> 75 million to 200 million people. Kennedy describes the devastation and huge social upheavals that resulted from this pandemic. Until then, the Roman Catholic Church dominated society. But:</p>
<blockquote>
<p>During the Black Death and subsequent plague outbreaks, people looked to the Church for comfort. All too often they didn’t find it. </p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=486&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=486&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=486&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=611&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=611&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517616/original/file-20230327-22-23ih7j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=611&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Black Death killed an estimated 75–200 million people in Europe and North Africa. Hugo Simberg Black Death.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This led to the rise of Protestantism, aided by the invention of the printing press - a shortage of labour encouraged the development of such labour-saving devices. Over the next 200 years, waves of plague repeatedly hit Europe. A quarantine system was developed in Venice, and <em>cordon sanitaires</em> established, to prevent movement of people between cities - ring any bells? </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/did-the-black-death-give-birth-to-modern-plagues-3820">Did the Black Death give birth to modern plagues?</a>
</strong>
</em>
</p>
<hr>
<h2>Pathogens as New World killers</h2>
<p>In the period from 1500 onwards, white colonialists nearly wiped out indigenous people by infecting them. Kennedy starts with the early 16th century, when Spanish conquistador Hernán Cortés led an expedition to Mexico. His arrival <a href="https://theconversation.com/how-smallpox-devastated-the-aztecs-and-helped-spain-conquer-an-american-civilization-500-years-ago-111579">introduced smallpox</a>, which resulted in the total destruction of the Aztec Empire within just two years. However, this was just the start. </p>
<p>In the early 1530s, Mexico was hit by an epidemic of <a href="https://theconversation.com/measles-new-efforts-needed-to-stop-an-old-disease-13706">measles</a> that killed 80% of its population, making it the deadliest epidemic in recorded history. Over the following decades, across the whole of the Americas, the introduction of infectious diseases from Europe resulted in a 90% fall in the population. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=441&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=441&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=441&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517624/original/file-20230327-15-s0x2ks.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hernán Cortés brought smallpox to Mexico, resulting in the total destruction of the Aztec Empire within two years, as illustrated in this 16th-century drawing of Aztec smallpox victims.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>However, during this period, it wasn’t just the New World that was profoundly affected by pathogens. On the west coast of Africa, explorers and would-be colonialists died in droves from <a href="https://theconversation.com/worlds-first-mass-malaria-vaccine-rollout-could-prevent-thousands-of-children-dying-169457">malaria</a> and <a href="https://theconversation.com/zika-dengue-yellow-fever-what-are-flaviviruses-53969">yellow fever</a>. </p>
<p>Interestingly, Kennedy starts his chapter on revolutionary plagues with the murder of <a href="https://theconversation.com/george-floyd-deserved-a-better-life-a-new-book-charts-his-trajectory-from-poverty-to-the-us-prison-industrial-complex-and-the-impact-of-his-death-182947">George Floyd</a> and the <a href="https://theconversation.com/the-black-lives-matter-movement-has-provoked-a-cultural-reckoning-about-how-black-stories-are-told-149544">Black Lives Matter</a> movement, before delving deep into the history of slavery. He describes slavery in Greek and Roman times, and the booming trade in slaves in the medieval Mediterranean. </p>
<p>The association between black Africans and <a href="https://theconversation.com/slavery-is-not-a-crime-in-almost-half-the-countries-of-the-world-new-research-115596">slavery</a> only began in the 15th century. In fact, only 3% of the 12.5 million humans trafficked across the Atlantic ended up in the United States. The most common destinations of the slave ships were the European colonies in the Caribbean, where African slave labour was first used more than a century before their shipment to North America. </p>
<p>Meanwhile, in the Caribbean, slave labour from tropical West Africa toiled on sugar plantations owned by the English, Spanish, French and Dutch. Yellow fever carried by mosquitoes wiped out many of the Europeans, including military garrisons, leading to slave revolts.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-a-slave-state-how-blackbirding-in-colonial-australia-created-a-legacy-of-racism-187782">Friday essay: a slave state - how blackbirding in colonial Australia created a legacy of racism</a>
</strong>
</em>
</p>
<hr>
<h2>Diseases ‘thrived’ in Dickensian habitats</h2>
<p>When Kennedy switches his focus to Britain, and the industrial revolution, he describes it as the change from a Thomas Hardy novel to one by <a href="https://theconversation.com/great-expectations-by-charles-dickens-class-prejudices-the-convict-stain-and-a-corpse-bride-159816">Charles Dickens</a>. The crowded and unsanitary conditions in working-class urban districts created new habitats, in which pathogens thrived. </p>
<p>Kennedy again evokes Monty Python to invoke the scenery of those days, reminding readers of the famous four Yorkshiremen sketch. The scene made me think of a different quote from the same sketch:</p>
<blockquote>
<p>You were lucky to have a house! We used to live in one room, all hundred and twenty-six of us, no furniture. Half the floor was missing; we were all huddled together in one corner for fear of falling!</p>
</blockquote>
<p>Every Epidemiology 101 course covers the story of <a href="https://www.newscientist.com/people/john-snow/">John Snow</a> (no – not the “Winter is coming” one!). <a href="https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section2.html">Two decades</a> before the development of the microscope, Snow examined cholera outbreaks to discover the cause of disease and how to prevent it. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=619&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=619&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=619&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=778&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=778&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517625/original/file-20230327-14-jix57.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=778&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">John Snow proved in 1854 that cholera is a waterborne disease: a London pub is named for him.</span>
<span class="attribution"><a class="source" href="https://www.geograph.org.uk/profile/6699">ceridwen/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>During the third UK cholera outbreak in 1854, Snow famously removed London’s Broad Street water pump, to demonstrate that cholera was a waterborne disease. For those interested, there is a <a href="https://londonspubswherehistoryreallyhappened.wordpress.com/2019/03/05/john-snow/">John Snow</a> pub in London. Kennedy, of course, includes this story in his book.</p>
<p>Kennedy points out that 3.5 billion people – half of the world’s population – have no access to proper toilets, while a billion don’t have clean drinking water and 1.5 million people, mainly children, die every year from waterborne diarrhoeal diseases. </p>
<p>We still have massive <a href="https://theconversation.com/explainer-why-cholera-remains-a-public-health-threat-74444">cholera outbreaks</a>, especially in areas where normal life has been disrupted by war or natural disasters. <a href="https://theconversation.com/tuberculosis-kills-as-many-people-each-year-as-covid-19-its-time-we-found-a-better-vaccine-151590">Tuberculosis</a> still kills 1.2 million people a year, despite the availability of antibiotics. Malaria kills another 600,000. </p>
<p>Finally in this section, he briefly covers <a href="https://theconversation.com/covid-hospitalisations-and-deaths-are-rising-faster-than-cases-but-that-doesnt-mean-more-severe-disease-187163">COVID</a>. He points out that not everyone in the world benefited from the medical advances that came about because of COVID, and the self-interested actions of high-income countries have deprived the poorer countries. As he puts it, “pathogens thrive on inequality and injustice”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fleas-to-flu-to-coronavirus-how-death-ships-spread-disease-through-the-ages-137061">Fleas to flu to coronavirus: how 'death ships' spread disease through the ages</a>
</strong>
</em>
</p>
<hr>
<h2>Future plagues</h2>
<p>Kennedy concludes by looking at future plagues. He points out humanity’s precarious position: we live on a planet dominated by bacteria and viruses. He believes our best chance of surviving the threat posed by pathogens will come from working collaboratively and reducing inequality both within and between countries. </p>
<p>Based on its title, I assumed this book would be about the role of pathogens in shaping civilisation. Instead, I found a social history of the world, with the odd foray into diseases and their influence on society. Nonetheless, I thoroughly enjoyed the book, and can highly recommend it to those with an interest in history, sociology and epidemiology.</p><img src="https://counter.theconversation.com/content/201569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adrian Esterman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>This whirlwind tour of social history describes how infectious diseases have shaped humanity at every stage. It suggests reducing inequality will give us our best chance of surviving future plagues.Adrian Esterman, Professor of Biostatistics and Epidemiology, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2011002023-04-04T14:26:08Z2023-04-04T14:26:08ZFake medicines are a dangerous threat in Africa: 3 ways to spot them<figure><img src="https://images.theconversation.com/files/519497/original/file-20230405-28-f2172w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The most common fakes tend to be the most popular medicines: painkillers, antibiotics.</span> <span class="attribution"><span class="source">Riccardo Mayer/Shutterstock</span></span></figcaption></figure><p>At the end of a long day, you realise you’re starting to get a headache. So you buy painkillers from the street vendor, and take two. But how do you know what those pills really are? The vendor isn’t a pharmacy. There’s no package insert listing ingredients or dosage instructions. What if you’ve just tried to treat your headache with counterfeit medicine?</p>
<p>The term “counterfeit medicine” refers to medicines <a href="https://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_23-en.pdf">that are</a> deliberately and fraudulently falsified or mislabelled. Also called sub-standard or falsified medicines, they would have failed to pass the quality measurements and standards which are approved by medicine regulatory authorities. They aren’t to be confused with generic medicines – those are cheaper, but still scientifically proven to be safe and efficacious versions of patented medicines. </p>
<p>The most common fakes <a href="https://www.oecd-ilibrary.org/sites/fe58fe07-en/index.html?itemId=/content/component/fe58fe07-en">tend to be</a> the most popular medicines: painkillers, antibiotics to treat infection, anti-malarials, anti-retrovirals, sexual stimulants, or weight loss medications. </p>
<p>Counterfeit medicines are a huge problem in many African countries. Research has shown that many developing countries have a high prevalence of substandard medicines. For instance, up to 88.4% of <a href="https://www.jvbd.org//article.asp?issn=0972-9062;year=2019;volume=56;issue=4;spage=288;epage=294;aulast=Arora">antimalarials</a> in some African markets have been reported as being fake. Using ineffective medicines causes <a href="https://www.who.int/publications/i/item/9789241513432">between</a> 64,000 and 158,000 deaths from malaria every year in sub-Saharan Africa.</p>
<p>Giving people medicine that won’t work or isn’t made properly is obviously dangerous. Over <a href="https://www.ajtmh.org/view/journals/tpmd/100/5/article-p1058.xml">250,000 children worldwide</a> die from these medicines each year. In the past year alone <a href="https://www.who.int/news/item/23-01-2023-who-urges-action-to-protect-children-from-contaminated-medicines">more than</a> 300 children died after ingesting counterfeit cough or pain syrups. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cough-syrup-can-harm-children-experts-warn-of-contamination-risks-199795">Cough syrup can harm children: experts warn of contamination risks</a>
</strong>
</em>
</p>
<hr>
<p>Work is underway to strengthen governments’ surveillance of counterfeit medicine. For instance, in many African countries <a href="https://gh.bmj.com/content/6/Suppl_3/e009367.full">pharmacists are being trained</a> to create awareness of such medicines and their possible infiltration into the medicine supply chain. This will make them better prepared to detect fake medicines and share information with their patients. </p>
<p>However, educating the end users of medicines – the patients – is the most important pillar of safe medicine use. Consumers must know how to visually inspect medicines for expiry dates and other identification markers. Being able to tell the difference between a good quality medicine and a fake one can make the difference between life and death. </p>
<p>As a pharmaceutical expert, I want to share my advice on three steps to take to spot a fake.</p>
<h2>Buy your medicines from legitimate places</h2>
<p>First, buy your medicines from licensed retail shops, pharmacies and dispensaries - they should display their licences on their walls. Pharmacists and their assistants are trained in the handling of medicines. They’re legally and ethically liable for the medicines under their control. This means they’ll source products through formal medicine channels which are less likely to be infiltrated by fakes. </p>
<p>Pharmaceutical personnel are also involved in their country’s pharmacovigilance system, which monitors the safety of medicines. It’s able to pick up and report serious side effects and injuries which may be caused by medicines. This system makes it possible to remove fake medicines. </p>
<p>Do not buy medicines from online pharmacies. In <a href="https://www.fip.org/file/5082">most</a> African countries, there are no legitimate online-only pharmacies. Legitimate online pharmacies should also have a physical presence in the country. <a href="https://awarerx.s3.amazonaws.com/system/redactor_assets/documents/179/NABP_Internet_Drug_Outlet_Report_Apr2013.pdf">Research</a> <a href="https://books.google.co.za/books?hl=en&lr=&id=_55UDQAAQBAJ&oi=fnd&pg=PP5&dq=he+internet+is+the+largest+source+of+counterfeit+drugs&ots=pBSol7xy3k&sig=86hJj55_c7UKc0aQuewIDW0YQyY&redir_esc=y#v=onepage&q=he%20internet%20is%20the%20largest%20source%20of%20counterfeit%20drugs&f=false">shows</a> that the internet is the largest source of counterfeit goods as most traders operate outside national borders and national laws governing the quality of medicines and their proper handling.</p>
<p>Buying medicines from unregulated markets may seem to be cheaper, but it’s extremely risky.</p>
<h2>Inspect your product</h2>
<p>Make sure to visually inspect the medicine’s external packaging.</p>
<p>It should be labelled with the product name, the details of the manufacturer – such as their name and physical address – and its expiry date. Where possible, check the batch number – this is a serial code which can be used to trace when and where the product was made. </p>
<p>If it’s a product you have used before, try to match it with previous packaging. Take a photograph of the product if you’re using it often for future comparison. </p>
<h2>Make sure the product is intact</h2>
<p>Open the package and ensure that the medication is intact. Tablets, for instance, may be blister-packed. Make sure that the blisters have not been tampered with and the seal hasn’t been broken. The blisters must all look the same and possess an expiry date and the name of the product. If the product is packaged as loose tablets or capsules in a bottle or dispenser packaging, ensure that they look uniform with no obvious discoloration, mottling (the skin of the pills looks marbled), chipping or mould. </p>
<p>Some powder residue in pills is acceptable, but there shouldn’t be too much at the bottom. This could mean the tablets are not well compressed. There should be no smell, for instance of vinegar. Capsules should be shiny and not cracked, sticky or clumped.</p>
<p>Oral liquids are more difficult to assess, but a bad odour or industrial or petrol-like smell is a sign of poor quality. The liquid should be easy to pour into a spoon and come out smoothly without clumps or solid particles. Liquids easily get contaminated with mould or bacteria so the bottle should be well sealed at the point of dispensing and when being used. Any remaining dose should be discarded within a month. Antibiotics should be discarded within seven days of opening if they have not been finished for whatever reason.</p>
<h2>When you’ve spotted a fake</h2>
<p>If you suspect that your medicine is of poor quality or fake, then you should report it to the clinic, pharmacy or national medicine regulator. Every country in Africa has a national medicine regulatory authority either as an independent agency or within the health ministry.</p><img src="https://counter.theconversation.com/content/201100/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David R. Katerere receives funding from SAMRC</span></em></p>Being able to tell the difference between good quality medicines and fakes can be a matter of life and death.David R. Katerere, Research Platform Chair for Pharmaceutical and Biotech Advancement in Africa (PBA2), Tshwane University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2007532023-03-07T10:10:16Z2023-03-07T10:10:16ZA new invasive mosquito has been found in Kenya – what this means for malaria control<figure><img src="https://images.theconversation.com/files/513173/original/file-20230302-19-92bytq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Malaria transmission in Kenya has been largely limited to the coast and western parts of the country.</span> <span class="attribution"><span class="source">Shutterstock </span></span></figcaption></figure><p>The Kenya Medical Research Institute <a href="http://kemri.go.ke/wp-content/uploads/2023/02/Evidence-Brief-Anopheles-stephensi-in-Kenya-potentially-substantial-threat-to-malaria-transmission-in-urban-and-rural-areas.pdf">recently detected</a> an invasive mosquito species in Laisamis and Saku subcounties of Marsabit county in Kenya’s northern region. </p>
<p>This mosquito, <em>Anopheles stephensi</em>, is native to South Asia and the Middle East. It <a href="https://pubmed.ncbi.nlm.nih.gov/33496217/">transmits the two malaria parasites</a> that pose the greatest risk of severe illness and death: <em>Plasmodium falciparum</em> and <em>Plasmodium vivax</em>. </p>
<p>The detection of this mosquito poses a major public health threat to Kenya for several reasons. </p>
<p>Malaria transmission in Kenya has been largely limited to the coast and western parts of the country. This is far from its major urban centres. The areas where <em>Anopheles stephensi</em> has been detected are urban and peri-urban. This mosquito thrives in urban settings. </p>
<p>Until now, Kenya’s malaria transmission has been driven by <a href="https://www.kemri.go.ke/wp-content/uploads/2023/02/"><em>Anopheles gambie</em></a> and <a href="https://www.kemri.go.ke/wp-content/uploads/2023/02/"><em>Anopheles funestus</em></a>. These vectors don’t cope very well with polluted water in urban centres.</p>
<p><em>Anopheles stephensi</em> on the other hand, <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-016-1321-7">can breed in</a> cisterns, jerrycans, tyres, open tanks, sewers, overhead tanks, underground tanks and polluted environments. Furthermore, the mosquito is invasive. It spreads very fast to new areas. It can adapt to various climatic conditions, unlike the non-invasive malaria vectors whose survival in cold temperatures in high altitude areas is restricted.</p>
<p>The invasion by this mosquito could pose a significant threat to Kenya’s efforts to control and eliminate malaria. The country must take immediate action to assess the threat and put prevention strategies in place. </p>
<h2>What are the consequences?</h2>
<p>If <em>Anopheles stephensi</em> were to spread in a city like Nairobi, the consequences would be serious. </p>
<p>First, malaria could spread to the inner-city areas. Until now, these areas have had little or no transmission and their populations have not acquired immunity against malaria. </p>
<p>Secondly, urban development would no longer be assumed to contribute to malaria elimination. Urbanisation has added to many health problems. But it has tended to “<a href="https://www.nature.com/articles/s41586-019-1050-5">build out</a>” malaria through better housing and gradual pollution of the landscape. Traditional malaria vectors can’t breed in small containers or in water with organic pollution. The new invasive species may mean that the development of new suburbs is building malaria into the landscape.</p>
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Read more:
<a href="https://theconversation.com/mosquito-species-from-asia-poses-growing-risk-to-africas-anti-malaria-efforts-188837">Mosquito species from Asia poses growing risk to Africa's anti-malaria efforts</a>
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<p>Traditional malaria vectors are <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-021-03891-z">already finding space</a> in urban areas because of extensive urban agriculture, untended green space, and unplanned urban sprawl with poor water management. Some of these characteristics have enabled mosquito vectors to maintain malaria transmission, in some cases like in Bioko Island, Equatorial New Guinea, at <a href="https://link.springer.com/article/10.1186/1756-3305-5-253">prevalence rates</a> as high as 30% to 40%. </p>
<p>There is also the risk that malaria from the cities will be exported to the rural areas. Regions in western Kenya and the coast are likely to suffer from spikes especially during the seasons where town dwellers visit during holiday seasons like Christmas.</p>
<p>The densely populated urban centres in these regions are likely to suffer the most. They are <a href="https://www.pnas.org/doi/10.1073/pnas.2003976117">seen as</a> highly suitable for <em>Anopheles stephensi</em> expansion due to the high population and conducive environmental and ecological factors like warm temperatures.</p>
<p>Traditional anti-malaria tools such as insecticide residual spraying are harder to use against <em>Anopheles stephensi</em> because its resting and feeding behaviour are different from other vectors.</p>
<p><em>Anopheles stephensi</em> has also proved to be <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-021-03801-3">resistant</a> to most of the publicly available insecticides.</p>
<h2>A few solutions</h2>
<p>What can be done to stop the spread of this invasive species: </p>
<ul>
<li><p>Increase collaboration and encourage integrated management. Since this is an urban malaria vector, the ministries of agriculture, health, education, environment, sanitation and water resources and county governments all need to work together. National responses to <em>Anopheles stephensi</em> should be integrated with efforts to control malaria and other mosquito-borne diseases, such as dengue fever, yellow fever and chikungunya. </p></li>
<li><p>Develop guidance for national malaria control programmes on appropriate ways to respond to <em>Anopheles stephensi</em>.</p></li>
</ul>
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<strong>
Read more:
<a href="https://theconversation.com/invasive-mosquito-species-could-bring-more-malaria-to-africas-urban-areas-147530">Invasive mosquito species could bring more malaria to Africa's urban areas</a>
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<li><p>Strengthen surveillance. The extent of the spread and the impact <em>Anopheles stephensi</em> has on malaria transmission in Kenya is not clear yet. Confirming both would be important in laying down management strategies to protect against disease outbreaks, particularly in urban settings, in the coming years. </p></li>
<li><p>Improve information exchange. Awareness of <em>Anopheles stephensi</em> should be boosted in communities most at risk. They should be advised to frequently replenish stored water for domestic use. People must also keep their environments free of discarded containers as these could be good breeding grounds for this invasive species.</p></li>
<li><p>A global policy and cross-border collaboration between the affected countries. Eradicating <em>Anopheles stephensi</em> from the Horn of Africa would be much cheaper in the long run than leaving it to spread to towns and cities.</p></li>
</ul><img src="https://counter.theconversation.com/content/200753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eunice Anyango Owino receives funding from National Research Fund of Kenya (NRF) and International Foundation For science. </span></em></p>This mosquito spreads very fast to new areas and can adapt to various climatic conditions, unlike the non-invasive malaria vectors.Eunice Anyango Owino, Medical Entomologist at the School of Biological Sciences, University of NairobiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2007452023-02-27T15:11:03Z2023-02-27T15:11:03ZJimmy Carter: the American president whose commitment to Africa went beyond his term<figure><img src="https://images.theconversation.com/files/512423/original/file-20230227-633-v0xzc6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Former American President Jimmy Carter. </span> <span class="attribution"><span class="source"> Drew Angerer/Getty Images</span></span></figcaption></figure><p>The office of former US president Jimmy Carter (98), who has been frail for some time, has <a href="https://cartercenter.org/news/pr/2023/statement-on-president-carters-health.html">announced</a> that he will no longer seek hospital treatment for his ailments. He has instead opted for hospice care at his modest home in the rural farming village of <a href="https://www.washingtonpost.com/nation/2023/02/20/plains-georgia-jimmy-carter">Plains, Georgia</a>, close to where he was born.</p>
<p>His opposition to racism and his support for human rights are legendary, made more compelling by his life-long commitment to live among rural Georgians where segregation was severe and discrimination remains prevalent today. This enduring commitment to non-racialism and human rights at home also shaped his interest and engagement in Africa.</p>
<p>We discussed African affairs often during the nine years (2006-2015) when I directed the Carter Centre <a href="https://www.cartercenter.org/peace/index.html">Peace Programmes</a>. My most frequent trips to Africa for the centre were to lead election observation missions, in which he was keenly interested.</p>
<p>His views on Africa can be assessed from three angles:</p>
<ul>
<li><p>Africa policies pursued during his presidency, 1977-1981</p></li>
<li><p>Programmes in Africa with the Carter Centre while he was its leader, 1982-2015 </p></li>
<li><p>His moral determination to reckon with racism.</p></li>
</ul>
<h2>Africa policies</h2>
<p>In her book <a href="https://www.amazon.com/Jimmy-Carter-Africa-International-History/dp/0804793859">Jimmy Carter in Africa: Race and the Cold War</a> Nancy Mitchell, a professor of history at North Carolina State University, analyses in 900 pages how Carter’s leadership and core values, discussed in the third section, influenced his approach to southern African. But Michell reminds us that in the 1970s Africa was the hottest theatre of the Cold War. </p>
<p>The book’s subtitle, however, highlights a significant shift of emphasis skilfully effected by Carter and key to his success in helping liberate Rhodesia (today Zimbabwe) by treating all sides, even “Communists”, with <a href="https://www.nytimes.com/2023/02/25/opinion/from-carter-to-mtg-what-a-peach-state-plummet.html%5D(https://www.nytimes.com/2023/02/25/opinion/from-carter-to-mtg-what-a-peach-state-plummet.html">respect</a>. Carter’s behind-the-scenes role in supporting the 1979 <a href="https://sas-space.sas.ac.uk/5847/5/1979_Lancaster_House_Agreement.pdf">Lancaster House agreement</a>, which led to Zimbabwean independence, was among his greatest diplomatic achievements.</p>
<p>Many years later, I was told by a close advisor to longtime Zimbabwean leader Robert Mugabe that, had Carter won a second term, he said he would work to raise US funds to facilitate a key element of the peace accord, land reform based on ‘willing seller, willing buyer’.</p>
<p>The election of Republican Ronald Reagan in 1980, however, resulted in a very different US policy of “<a href="https://michiganintheworld.history.lsa.umich.edu/antiapartheid/exhibits/show/exhibit/students-take-campus--1984-198/national-context--president-re">constructive engagement</a>” in southern Africa. It was widely perceived among anti-aparthed groups in the US and presumably in Africa as helping to ease the pressure of the Carter era against White minority rule. </p>
<p><a href="https://www.amazon.com/Power-Lines-Years-Africas-Borders/dp/0792241010">Southern Africa</a> remained Carter’s top priority, as Mitchell notes: </p>
<blockquote>
<p>Given their druthers, the Africa specialists in the Carter administration would have devoted their full attention to resolving the problems of Rhodesia, Namibia and South Africa. (p. 253)</p>
</blockquote>
<p>Carter told me several times that he spent more time pursuing peace in southern Africa than he did on the Middle East, and having read now declassifed files in the Centre library, I agree. </p>
<h2>Post-presidency</h2>
<p>Africa has claimed the lion’s share of resources and energy since President and Mrs Rosalynn Carter founded their <a href="https://cartercenter.org">centre</a> in partnership with Emory University 41 years ago, to work in poor nations, where colonialism and racism, had curtailed growth, opportunity and the sense of shared humanity. In 2015, their grandson Jason Carter, who lived in South Africa as a Peace Corps volunteer and speaks one of the country’s 11 official languages, isiZulu, was elected chair of the centre.</p>
<figure class="align-center ">
<img alt="An elderly man and a woman attach siding to the front of a Habitat for Humanity home." src="https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512424/original/file-20230227-572-110fn1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Former US president Jimmy Carter and his wife Rosalynn Carter attach siding to the front of a Habitat for Humanity home in 2003 in LaGrange, Georgia.</span>
<span class="attribution"><span class="source">Erik S. Lesser/Getty Images</span></span>
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<p>Africa remains the region of the <a href="https://www.cartercenter.org/about/index.html">Carter Centre</a>’s biggest and most enduring commitments, under its motivating slogan “Waging Peace, Fighting Disease, Building Hope”. According to the <a href="https://www.cartercenter.org/resources/pdfs/news/annual_reports/annual-report-21.pdf">2021 financial report</a>, the centre’s annual fundraising campaign raises about US$300 million annually. It now operates with a core staff in Atlanta of about 230 and field staff, mostly in Africa, of some 3,100. The centre also has an endowment fund in excess of US$1 billion.</p>
<p>The Carter Centre’s most significant contributions to development have been in the field of <a href="https://cartercenter.org/health/index.html">African public health</a>, to end, mitigate and prevent six diseases, among them malaria and river blindness. </p>
<p><a href="https://cartercenter.org/peace/democracy/index.html">Democracy</a> is the biggest of the peace programmes; election observation and support claim the greatest amount of resources and personnel. </p>
<h2>Carter’s moral compass</h2>
<p>Motivations for Carter’s interest in Africa are deeply personal. A brief address at a staff celebration of his <a href="https://www.cartercenter.org/news/editorials_speeches/jimmy-carter-90th-birthday-remarks.html">90th birthday</a> revealed his own reckoning with race at home. This, I believe, may have driven his long involvement in Africa.</p>
<p>Having grown up in tightly segregated rural Georgia, he recalled that his family was:</p>
<blockquote>
<p>completely surrounded by African-American children, with whom I played and worked in the fields and hunted and fished in the woods. And I got to know, eventually and slowly, the difference between a privileged group and the ones around us who were not permitted to vote, or to serve on a jury, or to go to a decent school.</p>
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<p>He added:</p>
<blockquote>
<p>I think this, more than anything else, has shaped my life — partially because of the guilt I still feel in not having recognised that disparity between us early on. I took it for granted that if the Supreme Court and the Congress and the American Bar Association and the universities and the churches said it was OK for white people to be superior, that was OK with God. And I think that that experience has been the most overwhelming factor in shaping my life …</p>
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<p>Carter, as I discovered, can be a hard man to work for. He holds himself and those around him to extremely high moral and ethical standards. As president, he kept the peace, told the truth, and obeyed the law. Carter also promised never to profit from the presidency – a pledge, from my observation, that he has scrupulously honoured.</p>
<p>His record should remind all democrats, including those in Africa, to hold leaders accountable to similar standards. For as he declared during his <a href="https://www.nobelprize.org/prizes/peace/2002/carter/lecture/">2002 Nobel Peace lecture</a>:</p>
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<p>The bond of our common humanity is stronger than the divisiveness of our fears and prejudices. God gives us the capacity for choice.</p>
</blockquote><img src="https://counter.theconversation.com/content/200745/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John J Stremlau does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The motivations for Carter’s interest in Africa are deeply personal. His record should remind all democrats, including those in Africa, to hold leaders accountable to high ethical standards.John J Stremlau, Honorary Professor of International Relations, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1979332023-02-14T13:43:23Z2023-02-14T13:43:23ZAl-Shabaab attacks in Somalia affect communities as far as 900km away – aid agencies need to take note<figure><img src="https://images.theconversation.com/files/506619/original/file-20230126-12-jm23rr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A soldier stands guard at a makeshift camp in Somalia's Baidoa, a southwestern town frequently attacked by Al-Shabaab militants.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Policymakers tend to assume that the effects of conflict are felt only where violence occurs. As a result, humanitarian aid, protection efforts or asylum policies largely focus on conflict-hit areas. </p>
<p>The <a href="https://www.who.int/">World Health Organisation</a>, for instance, provides emergency medical supplies in areas directly affected by violence. The <a href="https://www.unhcr.org/en-us/6328ce824.pdf">UN Refugee Agency</a> ties protection status to residing in areas hit by conflict. </p>
<p>Our <a href="https://docs.iza.org/dp15761.pdf">recent study</a> finds, however, that conflict negatively affects food security, nutrition, health and education outcomes of families living hundreds of kilometres away from the epicentre of violence. </p>
<p>This underscores the need to broaden policy responses to conflict and consider its ripple effects. </p>
<p>Our research in Somalia examined how the impact of violent conflict spread to distant locations. We looked specifically at conflict that affected Somalia’s food logistics network, which gets food to far-flung markets.</p>
<p>We focused on Somalia because of its high number of terror incidents arising from the government’s war with <a href="https://theconversation.com/what-drives-al-shabaab-in-somalia-foreign-forces-out-sharia-law-in-and-overthrow-the-government-191366">Al-Shabaab</a>, a militant group that has terrorised the country’s southern region for about 15 years.</p>
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Read more:
<a href="https://theconversation.com/al-shabaab-is-just-a-symptom-of-somalias-tragedy-the-causes-are-still-in-place-197554">Al-Shabaab is just a symptom of Somalia’s tragedy – the causes are still in place</a>
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<p>We used data from the <a href="https://www.fao.org/home/en">Food and Agricultural Organisation</a>, which tracks food prices. Our results show that terrorist attacks that hit food transportation networks increased food prices in markets located up to 900km away (a 17-hour drive) from where the violence occurs. </p>
<p>In response to these terrorist attacks and resulting price increases, households in far-flung areas adjusted their eating patterns. They also reduced their non-food spending, primarily on health and education. </p>
<p>Yet, the responses to violent incidents by donor and aid agencies, as well as domestic policymakers, hardly take such ripple effects into consideration. </p>
<h2>Tracking conflict</h2>
<p>To track these ripple effects, we focused on the distribution of maize, a staple food eaten throughout Somalia. We got the geo-coordinates of maize growing areas, tracked how maize was transported by road to markets, and mapped the Al-Shabaab terrorist attacks that occurred along these transport routes. </p>
<p>This helped us map the impact of conflict on maize prices and the ripple effects on household welfare. </p>
<p><a href="https://fews.net/">The Famine Early Warning Systems Network</a> provides maps showing the exact routes taken by Somali drivers who are transporting maize. We drew a corridor of five kilometres around these roads and counted the number of violent incidents occurring each month between 2001 and 2018. The <a href="https://www.fao.org/home/en">Food and Agricultural Organisation</a> provided us with monthly maize price information for 10 markets across Somalia. </p>
<p>We combined this data with <a href="https://microdata.worldbank.org/index.php/catalog/3181">World Bank surveys</a> that recorded food consumption, eating patterns, and the health and education of Somali families. </p>
<h2>Our findings</h2>
<p>We <a href="https://docs.iza.org/dp15761.pdf">found that</a> conflict along transportation roads increased maize prices substantially, even in markets located hundreds of kilometres away. This finding is in line with studies on the impact of conflict on supply chain networks elsewhere in the world, such as in the <a href="https://theconversation.com/russia-ukraine-crisis-highlights-africas-need-to-diversify-its-wheat-sources-181173">Russia-Ukraine war</a>.</p>
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Read more:
<a href="https://theconversation.com/russia-ukraine-conflict-is-driving-up-wheat-prices-this-could-fuel-instability-in-sudan-180878">Russia-Ukraine conflict is driving up wheat prices: this could fuel instability in Sudan</a>
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<p>During the height of the Al-Shabaab insurgency in Somalia (between 2016 and 2018), violent incidents occurring very close to transportation roads alone increased maize prices by around 11% over sustained periods of time.</p>
<p>During these times, we found violence en route had around half as large an impact on maize prices as rainfall, which the World Bank has highlighted as one of the most important <a href="https://openknowledge.worldbank.org/handle/10986/27379">determinants of food prices</a>. </p>
<p>We also scrutinised satellite images of nightlights emitted on transportation roads. We found that conflict along transit roads dimmed the light emitted on these roads several hundreds of kilometres away. This decrease in road traffic underscores a reduction in the quantity of maize transported along roads from growing areas to markets.</p>
<p>Looking at family welfare, we found that households reported having to adjust their eating patterns due to food price shocks. Families substituted the more expensive maize with sorghum. Still, we found that lower food security decreased the nourishment available to households.</p>
<p>Considering child outcomes, we found that far-away conflict along transit routes increased the incidence of diseases, such as gastroenteritis, malaria and typhoid. This is in line with <a href="https://gdc.unicef.org/resource/relationship-between-childhood-malnutrition-infectious-diseases">well-known links</a> between malnutrition and infectious diseases. </p>
<p>Finally, we also found a decrease in the school enrolment of children. Violent incidents along maize transportation routes reduced the probability of children joining primary and middle school hundreds of kilometres away. This is likely to be related to the economic effects of food price rises. This makes schooling less affordable and increases the incentives for child labour. </p>
<h2>Way forward</h2>
<p><a href="https://docs.iza.org/dp15761.pdf">Our study</a> has wide-ranging policy implications. </p>
<p>The ripple effects of violence have important welfare costs. The negative effects of conflict on human capital – particularly nutrition, health and education – are larger than commonly assumed. We estimate that these ripples add around 30% to the cost of locally occurring conflict. </p>
<p>Our findings also have important implications for the regional targeting of policies. </p>
<p>Humanitarian interventions or refugee policies most commonly focus on those locations where conflict occurs. The World Food Programme, for instance, provides nutritional assistance in areas around Mogadishu, in the south-west of Somalia where most conflict is concentrated. </p>
<p>Similarly, when evaluating asylum eligibility, the <a href="https://www.unhcr.org/en-us/6328ce824.pdf">UN Refugee Agency</a> highlights the south-west of Somalia as the area where individuals are at risk of serious harm. </p>
<p>By contrast, our results provide evidence that individuals can be affected by conflict even if it occurs far away. For instance, the city of Galkayo (700km from Mogadishu) is part of the north-eastern Puntland state. It isn’t covered by either the World Food Programme or the UN’s refugee policies. Yet conflict in the south-west increases food prices, decreases food security and erodes human capital in Galkayo. </p>
<p>This long reach of violence highlights the need to consider extending humanitarian aid, protection efforts or asylum status eligibility to areas further away from conflict epicentres.</p><img src="https://counter.theconversation.com/content/197933/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The negative effects of conflict on human capital – particularly nutrition, health and education – are larger than commonly thought.Marco Alfano, Lecturer, Lancaster UniversityThomas Cornelissen, Professor of Economics, University of EssexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1959972023-01-08T08:47:21Z2023-01-08T08:47:21ZHIV remains a leading killer in Africa despite medical breakthroughs – how to eliminate it<figure><img src="https://images.theconversation.com/files/500741/original/file-20221213-13937-sc773c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>About <a href="https://www.unaids.org/en/resources/fact-sheet">38 million</a> people around the world are living with HIV. About 70% of them live in Africa. This shows that there is no solution to the AIDS pandemic without a solution in Africa. In 2021, there were 1.5 million <a href="https://www.unaids.org/en/resources/fact-sheet">new cases</a> of HIV – just over 4,000 cases per day around the world. At the same time, close to <a href="https://www.unaids.org/en/resources/fact-sheet">700,000 people died</a>. The big challenge is to address the dual realities of people still dying from HIV in large numbers, and the large numbers of new infections. The upside is that there is a clear plan with clear goals on how to address this. In 2016, countries came together at the United Nations to <a href="https://www.unaids.org/en/resources/909090">agree</a> on what the world’s strategy should be. The goal is to end AIDS as a public health threat by 2030. We spoke with leading scientist Professor Salim Abdool Karim about how to close the gaps.</em></p>
<hr>
<h2>What are we getting wrong?</h2>
<p>It’s not like we’re doing something wrong, but you can always do better than what we do now. Most new infections are coming from two different groups.
The first is key populations. The largest number of new infections is occurring in <a href="https://www.unaids.org/sites/default/files/media_asset/2022-global-aids-update-summary_en.pdf">men who have sex with men</a>. Especially young men – often young black men. These infections occur largely in Eastern Europe and in Russia.</p>
<p>The second high priority is the large numbers of new infections in <a href="https://www.sciencedirect.com/science/article/pii/S2772707622001035">young women in Africa</a>. If we don’t address those two groups, we won’t solve the problem.
But to address those two groups is not easy. The challenges in much of Eastern Europe and Russia relate to their marginalisation and discrimination as much as they are about services for key populations.</p>
<p>In Africa, we have simply not been able to stem the number of new infections in young women to the extent we had hoped. The problem is the way in which society has supported or entrenched age disparate sex, where teenage girls are having sex with men about eight to 10 years older than them.</p>
<p>And the means we have to slow the rate of new infections in young women is not well suited to the need. It’s not feasible for a young woman who is not thinking about HIV and aware of her risk regularly to take a tablet every day or even to get an injection. So we have to develop new technologies.</p>
<p>We need a combination of new approaches in our society to reduce age disparate sex. And we need new technologies to protect young women. And thirdly, we need to get more young men and more men in their 20s and 30s into health services so that they test and they go on to treatment before they infect young girls.</p>
<h2>How do we change this?</h2>
<p>There are three things we have to think about.</p>
<p>The first is we must appreciate that each of us is mutually interdependent: each person’s risk affects the risk faced by others. Hence, we need solutions that involve everyone working towards a common purpose. We saw that very clearly in COVID-19. Omicron was first described in South Africa in November 2021 – within a week this variant was detected in 16 countries. Within two weeks omicron was in several countries on all continents. This shows that we are all interconnected and dependent on each other. We have a shared responsibility to deal with the problem. </p>
<p>We can’t take the attitude that it’s somebody else’s problem. In many ways, in HIV, the response has taken our interdependence into consideration. For example, wealthy countries put resources into the <a href="https://www.theglobalfund.org/en/">Global Fund to Fight AIDS, TB and Malaria</a> for poor countries to benefit. It’s a shared responsibility. The countries are not saying, “It’s Africa’s problem, we don’t care.” No, they’re saying, “We understand that if we don’t get HIV under control in Africa, it affects the whole world.”</p>
<p>Second is that we have to mobilise the resources to at least get treatment up to the levels that we have set in our targets. That means we have to get 95% of people knowing their HIV status, 95% of people with HIV on treatment, and 95% of them virally suppressed. This is the global target for 2025. We need to help each other to get to that target.</p>
<p>We’re going to need to do better with prevention. That’s the third point. Treatment is not going to be enough on its own to enable us to reach the 2030 target. We need to improve prevention. That means we’re going to need to continue our efforts in circumcision and condom promotion, and to do better with pre-exposure prophylaxis.</p>
<h2>What are the next steps?</h2>
<p>We need to build on the momentum from the COVID-19 pandemic. The introduction of new technologies such as <a href="https://medlineplus.gov/genetics/understanding/therapy/mrnavaccines/#:%7E:text=Currently%20vaccines%20for%20COVID%2D19,as%20the%20%E2%80%9Cspike%20protein%E2%80%9D.">mRNA</a> is a good example. This is technology we can tap to improve the research on vaccines against tuberculosis and malaria, particularly in HIV.
We don’t have a vaccine for HIV yet, but there are now new candidates being made with mRNA. At least we can do better with existing TB vaccines and existing malaria vaccines with a new platform such as using mRNA technology. It is also an important platform for HIV vaccines in the pipeline.</p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195997/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salim Abdool Karim does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We need a combination of new approaches to reduce age disparate sex. And we need new technologies to protect young women.Salim Abdool Karim, Director, Centre for the AIDS Program of Research in South Africa (CAPRISA)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1959962022-12-14T10:58:28Z2022-12-14T10:58:28ZTB is once again the deadliest disease in Africa - what went wrong<figure><img src="https://images.theconversation.com/files/500664/original/file-20221213-9592-576dx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Scientist analysis flasks of saliva of TB patients. </span> <span class="attribution"><span class="source">Yanick Folly/AFP via Getty Images</span></span></figcaption></figure><p>Effective tuberculosis (TB) treatment has been available for the past 60 years. But TB remains the <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden">leading cause of death</a> from a single infectious agent. It <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-2-tb-mortality">ranks above</a> HIV and AIDS and others. This is partly because of the impact of HIV co-infection among TB patients in places like Africa and emergency of MDR-XDR TB. Lack of both gender mainstreaming and reduction of stigma manifested by persistently lower reported cases among women that men is of continued concern.</p>
<p>COVID-19 surpassed TB as a killer over the past two years. The number of people dying from TB have been going down <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-2-tb-mortality">since 2005</a>. But now TB is again at number one. Between <a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-diagnosis-treatment/3-3-tb-treatment-and-treatment-coverage">2019 and 2021</a> the number of people provided with treatment for TB decreased – largely due to COVID-related lockdowns. In 2021, 61% of people with TB were receiving treatment, this is lower that 69% in 2020. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=370&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=370&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=370&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=465&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=465&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499765/original/file-20221208-7252-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=465&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tb-disease-burden/2-1-tb-incidence#fig--2-1-4">World Health Organization</a></span>
</figcaption>
</figure>
<h2>What went wrong?</h2>
<p>Progress in TB elimination was being made. But the COVID-19 pandemic and associated lockdowns have set back TB control programmes worldwide. More so in Africa. While COVID-19 prevention measures like mask-wearing could have prevented TB transmission, on the whole, little attention was given to holding the forts of TB prevention and treatment as all efforts went to fighting the COVID-19 pandemic, disrupting well-functioning programmes built over decades of careful research and planning. This disruption has resulted in the following:</p>
<p><strong>a) Increased TB cases:</strong> </p>
<p>In 2021, there were 10.6 million <a href="https://cdn.who.int/media/docs/default-source/hq-tuberculosis/global-tuberculosis-report-2022/global-tb-report-2022-factsheet.pdf?sfvrsn=88f8d76_8&download=true">new active TB cases</a> worldwide: up from 9.9 million in 2020. These increases have been in both drug sensitive and multi-drug resistant TB cases. </p>
<p><strong>b) Increased TB deaths:</strong></p>
<p>In 2021 there were an estimated 1.6 million deaths from TB worldwide: up from 1.5 million in 2020 and 1.4 million in 2019. This is a reversal of years of decline before the COVID-19 pandemic. A quarter (25%) of TB related deaths occur in the African region which has <a href="https://www.worldometers.info/world-population/africa-population/#:%7E:text=The%20current%20population%20of%20Africa,of%20the%20total%20world%20population.">around 16%</a> of world’s population. HIV being a main contributing factor. </p>
<p><strong>c) Decline in TB global spending during and after COVID-19 pandemic:</strong></p>
<p>Global spending on essential TB services dropped from US$6.0 billion in 2019 to US$5.4 billion in 2021. This is less than half of what is needed. The war in Ukraine has compounded this extended decline in TB prevention and control. Even before the <a href="https://www.lshtm.ac.uk/research/centres/health-humanitarian-crises-centre/news/343596/will-war-ukraine-lead-spike-tuberculosis-cases">Russian invasion</a>, Ukraine had a high TB rate. The war has exacerbated the situation with health facilities being destroyed and people displaced. African TB control programmes that rely on aid and Global Fund support have been affected most.</p>
<h2>How do we correct this?</h2>
<p>The first <a href="https://www.who.int/publications/i/item/WHO-HTM-TB-2015.19">End TB Strategy</a> milestones for reductions in TB disease should guide what needs to be done. This includes 20% reduction in 2015 TB incidence rates, and 35% reduction in total number of TB deaths benchmarked in 2015. Three high TB burden countries in Africa have reached or passed the first milestones of the End TB Strategy for both reductions in TB incidence and TB deaths: Kenya (in 2018), Tanzania (in 2019) and Zambia (in 2021). Ethiopia is very close. However, the larger part of the African continent has seen a reversal in gains made. </p>
<p>Intensified efforts to obtain funding are urgently required to mitigate and reverse the negative impacts of the COVID-19 pandemic on TB. This has become even more pressing in the context of ongoing conflicts in Africa and other parts of the world, which are likely to worsen some of the <a href="https://www.who.int/publications/digital/global-tuberculosis-report-2021/uhc-tb-determinants/determinants#:%7E:text=The%20tuberculosis%20(TB)%20epidemic%20is,alcohol%20use%20disorders%20and%20smoking.">broader determinants of TB</a> such as undernutrition. </p>
<p>Priorities for TB care should be:</p>
<ul>
<li><p>Increase budget and human resources for existing TB and TB/HIV services</p></li>
<li><p>Develop digital platforms for training and health education. Develop public-facing dashboards for TB surveillance data. Develop telemedicine with the use of digital platforms for consultation. Reduce loss to follow up</p></li>
<li><p>Strengthen community-based TB treatment services</p></li>
<li><p>Scale up virtual care, community-monitoring solutions to provide remote support such as video-supported therapy. Scale up SMS-based communication to improve treatment adherence and patient-centred care and support</p></li>
</ul>
<p>TB prevention should focus on: </p>
<ul>
<li><p>Target high-risk groups for universal testing, to find most or all missing active TB cases in communities</p></li>
<li><p>Strengthen community-based active case finding and tuberculosis diagnostic services (including in shelters for people who are homeless). </p></li>
<li><p>Integrate TB, HIV and COVID-19 services including screening and testing, case finding and prevention. </p></li>
<li><p>Enhance screening and case finding activities at health facilities, including targeting high-risk groups </p></li>
<li><p>Increased screening for TB in high-risk groups. Use rapid turnaround molecular tests with high sensitivity and specificity for dual diagnostic testing for TB and COVID-19</p></li>
<li><p>Expand use of chest radiography with or without computer-aided detection for TB, and improve facility-based screening</p></li>
<li><p>Ensure regular supply of diagnostics and drugs through local manufacturing.</p></li>
</ul>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195996/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tom Nyirenda is also the Strategic Partnerships and Capacity Development Manager at the European & Developing Countries Clinical Trials Partnership. </span></em></p>Intensified efforts to obtain funding are urgently required to mitigate and reverse the negative impacts of the COVID-19 pandemic on TB.Tom Nyirenda, Extraordinary Senior Lecture in the Department of Global Health , Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954792022-12-13T13:27:56Z2022-12-13T13:27:56ZHypertension, diabetes, stroke: they kill more people than infectious diseases and should get a Global Fund<figure><img src="https://images.theconversation.com/files/499986/original/file-20221209-19531-9yfpxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Noncommunicable diseases such as diabetes, hypertension and cardiovascular conditions account for <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">41 million deaths</a> each year. That’s more than 70% of all deaths globally. Most of these deaths (77%) are in low-income and middle-income countries – including those in Africa. </p>
<p>These conditions are currently <a href="https://www.researchgate.net/publication/356360474_Tanzania_Non-communicable_Diseases_and_Injuries_Poverty_Commission_Findings_and_Recommendations">more prevalent</a> than infectious diseases. Sixty-seven percent occur before the age of 40. Besides being the leading causes of death worldwide, noncommunicable diseases carry a <a href="https://apps.who.int/iris/handle/10665/274512">huge cost</a> to individuals. These also undermine workforce productivity and threaten economic prosperity.</p>
<p>Healthcare provision in much of Africa still relies on <a href="https://www.brookings.edu/blog/future-development/2019/03/01/closing-africas-health-financing-gap/">external donors</a>. There’s insufficient funding to help low-income and middle-income countries control noncommunicable diseases. Most <a href="https://jamanetwork.com/journals/jama/fullarticle/2320320">development assistance for health funding</a> provided by international donors is allocated for infectious diseases and maternal and child health. In <a href="https://vizhub.healthdata.org/fgh/">2019</a>, funding for HIV amounted to US$9.5 billion. The amount allocated to noncommunicable diseases was US$0.7 billion. </p>
<p>Evidence suggests that addressing the noncommunicable disease pandemic can also mitigate other challenges like HIV, tuberculosis (TB), maternal and child health, and universal health coverage. </p>
<p>The <a href="https://www.theglobalfund.org/en/">Global Fund</a> to Fight AIDS, TB and Malaria is an international partnership. The fund invests US$4 billion a year to fight these three diseases. </p>
<p>I believe it’s now time to think of establishing a Global Fund for noncommunicable diseases, or expand the mandate of Global Fund beyond AIDS, TB and malaria. The epidemics of these conditions overlap. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8872228/#:%7E:text=The%20most%20prevalent%20HIV%20comorbidities,and%20hepatitis%20C%20%5B14%5D.">research</a> has shown that <a href="https://jamanetwork.com/journals/jama/article-abstract/2757599">comorbidities</a> such as diabetes and cancers are common in people living with HIV. </p>
<h2>Broadening healthcare provision</h2>
<p>Disease specific programmes have <a href="https://academic.oup.com/heapol/article/33/3/381/4812662">limitations</a>. As public health practitioners we should learn from our mistakes. We must build integrated programmes and health systems that address the interlinkages and co-morbidities. One example would be to include diabetes screening in TB treatment programmes. </p>
<p>In addition to integration, noncommunicable diseases require increasing investments. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
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<p>The Global Fund is seeking US$18 billion this year. At the same time <a href="https://www.thelancet.com/ncd-countdown-2030">The Lancet NCD Countdown 2030</a> projects that interventions for noncommunicable diseases need US$18 billion a year. That’s what it would take to meet the UN target of reducing noncommunicable diseases by a third by the year 2030. </p>
<p>I would argue that the case for <a href="https://pubmed.ncbi.nlm.nih.gov/35339227/">investment</a> in noncommunicable diseases has never been stronger. </p>
<h2>A roadmap</h2>
<p>The World Health Assembly recently <a href="https://www.who.int/news-room/feature-stories/detail/world-health-assembly-approves-a-global-implementation-roadmap-to-accelerate-action-on-noncommunicable-diseases-(ncds)">approved</a> the World Health Organization’s roadmap for the prevention and control of noncommunicable diseases covering the period 2023-2030. </p>
<p>The roadmap recommends actions to: </p>
<ul>
<li><p>promote “best-buys” interventions with a high return for every dollar spent, such as smoking cessation programmes </p></li>
<li><p>strengthen health systems </p></li>
<li><p>reduce noncommunicable disease risk factors such as tobacco use and unhealthy diets </p></li>
<li><p>embed noncommunicable diseases within primary healthcare and universal health coverage. </p></li>
</ul>
<p>This roadmap needs to be followed in line with the commitments to reduce air pollution and promote mental health and well-being.</p>
<p>The lessons learned from the COVID-19 pandemic offer opportunities for strengthening emergency preparedness and responses beyond pandemics. Emergency risk management and continuity of essential health services for all hazards – addressing the foundational health system gaps – can improve health security.</p>
<h2>What should be done</h2>
<p>How should Africa respond to the increasing burden of noncommunicable diseases? There needs to be a strong political will and buy-in from governments, with strong multi-stakeholder participation. </p>
<p>The <a href="https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025">UN General Assembly</a> decision on HIV and noncommunicable diseases commits governments to identify and address the comorbidities of HIV and other links to pressing global health challenges. These include links to noncommunicable diseases, learning from the perspectives of people living with these conditions and underscoring the importance of focusing on comorbidities. </p>
<p>The WHO’s <a href="https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030#:%7E:text=The%20Global%20NCD%20Compact%202020,of%20people%20living%20with%20NCDs.">noncommunicable disease compact</a> proposes concrete actions. These actions need to be data-driven and supported by noncommunicable disease-related indicators in health systems performance and access to healthcare metrics. </p>
<p>Monitoring systems need to be more diverse. The systems should capture and monitor progress made through sectors that affect health, such as housing and sanitation. Doing this would strengthen the monitoring of national systems and the capacity to address noncommunicable diseases comprehensively.</p>
<p>Health system strengthening and quality of care will improve significantly with additional resources for noncommunicable diseases through an entity like the Global Fund. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaushik Ramaiya is Honorary General Secretary of Tanzania Diabetes Association and we work with Ministry of Health (Tanzania) in implementing National NCD program which has been funded by World Diabetes Foundation (WDF) and Novo Nordisk Foundation. </span></em></p>Addressing the noncommunicable disease pandemic can also mitigate challenges facing people living with HIV and complement efforts against TB.Kaushik Ramaiya, Honorary Professor of Medicine & Global Health , Liverpool School of Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1940662022-11-10T13:47:06Z2022-11-10T13:47:06ZClimate change affects mosquito behaviour. This may make it harder to end malaria in South Africa<figure><img src="https://images.theconversation.com/files/494228/original/file-20221108-20-5pc5g2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Global climate is changing rapidly. This has a range of public health implications. </span> <span class="attribution"><span class="source">CDC/ James Gathany</span></span></figcaption></figure><p>Changes in climatic factors – such as higher temperatures and increased rainfall – affect the developmental, behavioural and distribution patterns of <a href="https://theconversation.com/what-a-warmer-wetter-world-means-for-insects-and-for-what-they-eat-166509">insects</a> like mosquitoes. These changes have serious implications for the effective control of insect-borne diseases such as malaria.</p>
<p>Worryingly, temperatures across southern Africa are predicted to increase by at least <a href="https://www.climatelinks.org/sites/default/files/asset/document/Southern%20Africa%20Climate%20Info%20Fact%20Sheet_FINAL.pdf">0.8⁰C by 2035</a>.</p>
<p>Malaria is currently present in three provinces in South Africa: Limpopo, Mpumalanga and KwaZulu-Natal. Limpopo reports 62% of the local cases, while KwaZulu-Natal reports only <a href="https://malariaelimination8.org/south-africa">6%</a>.</p>
<p>Over the past 50 years annual temperatures in South Africa have been increasing significantly faster than the <a href="https://www.climatelinks.org/sites/default/files/asset/document/Southern%20Africa%20Climate%20Info%20Fact%20Sheet_FINAL.pdf">global average</a>. The increases have been most extreme in Limpopo, where temperatures have risen by an average of 0.12⁰C every decade. Small annual shifts have big effects.</p>
<p>These higher temperatures increase the malaria risk. This is because the malaria mosquito and parasite are happiest at <a href="https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.2003489">temperatures</a> between 17⁰C and 35⁰C. </p>
<p>Warmer weather means vector mosquitoes are able to <a href="https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-019-3391-1#:%7E:text=albopictus%20intrinsic%20rate%20of%20growth,females%20in%2027%20%C2%B0C.">develop faster</a>, invade new locations, and spread <a href="https://wellcome.org/news/how-climate-change-affects-vector-borne-diseases">vector-borne diseases</a>.</p>
<p>In addition, increased rainfall will potentially increase the number of mosquito vector <a href="https://wellcome.org/news/how-climate-change-affects-vector-borne-diseases">breeding sites</a>. Vector mosquitoes like those that transmit malaria breed in stagnant and temporary bodies of water. Research in Limpopo has <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6950450/">shown</a> that heavy rains in spring are usually associated with higher malaria case numbers during summer. </p>
<p>The impact of climate change on mosquitoes is very clear. But its impact on malaria transmission is still unclear. Some theoretical mathematical modelling studies <a href="https://www.sciencedirect.com/science/article/abs/pii/S003592030600263X">predict</a> an uptick in malaria case numbers due to climate change. But other models suggest climate change will have <a href="https://www.nature.com/articles/415905a">no impact on malaria</a>. More data are needed to see which model is correct. This is because the effect is difficult to test in the laboratory. </p>
<p>Whether climate change will present another challenge to achieving malaria elimination is yet to be confirmed. Our <a href="https://www.nicd.ac.za/centres/centre-for-emerging-zoonotic-and-parasitic-diseases/">research group</a> is currently trying to address this knowledge gap.</p>
<h2>What we do know</h2>
<p>The relationship between climate change and malaria is complicated. But four things are clear: as the Earth warms up the malaria vector will develop faster, allowing them to breed faster, bite <a href="https://wellcomeopenresearch.org/articles/2-102#ref-35">more frequently</a> and expand into formerly unsuitable habitats. </p>
<p>This means that mosquito larvae will develop into adults faster. The sooner the female bites, the sooner she can transmit the disease. If she bites more frequently, she will spread more disease. </p>
<p>The malaria parasite’s development inside the mosquito is highly dependent on temperature. At temperatures <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5658182/">below 17⁰C, and above 35⁰C</a>, the parasite’s life cycle inside the mosquito cannot be completed. This halts the onward transmission of malaria. </p>
<p>The mosquito’s transformation from larva to free-flying adult generally occurs at temperatures between <a href="https://www.cambridge.org/core/journals/bulletin-of-entomological-research/article/abs/effect-of-temperature-on-the-development-of-the-aquatic-stages-of-anopheles-gambiae-sensu-stricto-diptera-culicidae/6375ECAEF9B542ABB63F074E0972C855">22⁰C and 34⁰C</a>. Interestingly, research has <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146900/">shown</a> that mosquitoes can change their behaviour to spend most of their time resting in cooler spaces. This way they can survive when ambient temperatures increase. This behaviour of the mosquito can help the parasite survive temperatures that would otherwise stop its development. </p>
<p>Distinct changes in the <a href="https://geographical.co.uk/climate-change/as-the-world-warms-the-seasons-are-shifting">seasons</a>, largely due to climate change, have been noted. The <a href="https://www.climatelinks.org/sites/default/files/asset/document/Southern%20Africa%20Climate%20Info%20Fact%20Sheet_FINAL.pdf">southern African region</a> is experiencing more frequent extreme heat days and fewer extreme cool days.</p>
<p>Therefore, winters are becoming much warmer, allowing mosquitoes to breed and transmit malaria in larger numbers during the winter months. Summer months are also getting hotter. In some cases, the summers may get too hot for mosquito and parasite growth, preventing malaria transmission. Climate change could cause a shift in the malaria transmission season from the summer months to the traditionally cooler autumn and winter months.</p>
<p>Rainfall also plays a major role in malaria transmission. In general, malaria incidence decreases during the El Niño (hotter but drier) years and increases in the La Niña (cooler but wetter) <a href="https://www.sciencedirect.com/science/article/abs/pii/S003592030600263X">years</a>. This is particularly true in countries like South Africa, where the adaptable malaria vector, <em>Anopheles arabiensis</em>, is a dominant transmitting vector. South Africa is currently in a La Niña cycle, so the upcoming malaria season (October to February) could potentially be significant, given the more favourable conditions for malaria transmission and the relaxation of all COVID-related restrictions on movement. </p>
<h2>The South African situation</h2>
<p>Our research group based at the <a href="https://www.nicd.ac.za/centres/centre-for-emerging-zoonotic-and-parasitic-diseases/">National Institute for Communicable Diseases</a> and the University of Witwatersrand’s <a href="https://www.wits.ac.za/wrim/">Research Institute for Malaria</a> was involved in identifying the mosquitoes behind the malaria epidemic of <a href="https://resjournals.onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-2915.2000.00234.x?sid=nlm%3Apubmed">2000</a>. This outbreak coincided with severe <a href="https://earth.esa.int/web/earth-watching/natural-disasters/floods/content/-/asset_publisher/zaoP2lUloYKv/content/flood-mozambique-february-2000/">flooding</a> in southern Mozambique. The dramatic increase in available breeding sites allowed an insecticide-resistant mosquito from Mozambique, <em>Anopheles funestus</em>, to reinvade KwaZulu-Natal, driving malaria case numbers up.</p>
<p>Since this outbreak, our group has been conducting <a href="https://sajs.co.za/article/view/11755">intensive surveillance</a> in South Africa’s endemic provinces. We’ve also been involved in research to understand the impact of climate change on malaria transmission in South Africa. </p>
<p>Research from our vector laboratories has <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-018-2250-4">demonstrated</a> that a warmer world would reduce the effectiveness of insecticides used for indoor residual spraying. In addition, insecticide resistant mosquitoes <a href="https://malariajournal.biomedcentral.com/articles/10.1186/s12936-017-1720-4%20">seem better adapted</a> to surviving the warmer conditions than mosquitoes that are sensitive to insecticides.</p>
<p>Modelling experiments <a href="https://previous.iiasa.ac.at/web/scientificUpdate/2014/Abiodun_Gbenga.html">suggest</a> that humidity levels will also influence malaria transmission in South Africa. But this needs to be confirmed under laboratory conditions using live mosquitoes.</p>
<h2>What needs to be done?</h2>
<p>It is clear that the relationship between climate change and malaria is complex. More work needs to be done to understand this relationship so effective control measures can be put in place. Crucially, malaria hotspots should be targeted for surveillance in order to understand the role of microclimate on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146900/">malaria transmission</a>. Microclimate is a set of local climate conditions that may differ from the climate in general. </p>
<p>At present, there is no evidence that the <a href="https://www.nicd.ac.za/wp-content/uploads/2018/12/south_africa_malaria_risk_dec2018_final.pdf">malaria-risk areas</a> in South Africa have expanded. However, regardless of the climate or whether you have travelled this summer, it is critical to think about malaria when it comes to unexplained fevers. <a href="https://www.nicd.ac.za/uploads/2017/03/Malaria-FAQ-NICD-Nov-2018.pdf">Know</a> what the symptoms of malaria are, how to reduce the risk of being infected, and what to do if you suspect that you have malaria.</p><img src="https://counter.theconversation.com/content/194066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shüné Oliver receives funding from the National Research Foundation of South Africa, the National Health Laboratory Services Research Trust and the Female Academic Fellowship (FALF). </span></em></p><p class="fine-print"><em><span>Jaishree Raman is affiliated with National Institute for Communicable Diseases, the Wits Research Institute for Malaria and the UP Institute for Sustainable Malaria Control. She receives funding from the Global Fund, the Bill and Melinda Gates Foundation, the South African Medical Research Council, the South Africa Research Trust, the National Research Foundation and the National Institute for Communicable Diseases.</span></em></p>As the Earth warms up the malaria vector will develop faster, allowing them to breed faster, bite more frequently and expand into formerly unsuitable habitats.Shüné Oliver, Medical scientist, National Institute for Communicable DiseasesJaishree Raman, Principal Medical Scientist and Head of Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1930772022-11-10T13:41:45Z2022-11-10T13:41:45Z8 billion people: Four ways climate change and population growth combine to threaten public health, with global consequences<figure><img src="https://images.theconversation.com/files/494155/original/file-20221108-12-bg01z4.jpg?ixlib=rb-1.1.0&rect=522%2C226%2C3071%2C2166&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infectious diseases like COVID-19 top the list of health concerns.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-elderly-man-a-resident-of-the-sprawling-township-of-news-photo/1211082728">Marco Longari/AFP via Getty Images</a></span></figcaption></figure><p><em><a href="https://theconversation.com/ocho-mil-millones-de-personas-asi-amenazan-a-la-salud-publica-el-cambio-climatico-y-la-superpoblacion-194421">Leer in español</a></em></p>
<p>There are questions that worry me profoundly as a population- and environmental-health scientist. </p>
<p>Will we have enough food for a growing global population? How will we take care of more people in the next pandemic? What will heat do to millions with hypertension? Will countries wage water wars because of increasing droughts? </p>
<p>These risks all have three things in common: health, climate change and a growing population that the United Nations determined <a href="https://www.un.org/en/desa/world-population-reach-8-billion-15-november-2022">passed 8 billion</a> people in November 2022 – double the population of just 48 years ago.</p>
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<p>In my <a href="https://www.health.pitt.edu/people/ant-2">40-year career</a>, first working in the Amazon rainforest and the Centers for Disease Control and Prevention, and then in academia, I have encountered many public health threats, but none so intransigent and pervasive as climate change. </p>
<p>Of the multitude of climate-related adverse health effects, the following four represent the greatest public health concerns for a growing population.</p>
<h2>Infectious diseases</h2>
<p>Researchers have found that <a href="https://theconversation.com/58-of-human-infectious-diseases-can-be-worsened-by-climate-change-we-scoured-77-000-studies-to-map-the-pathways-188256">over half of all human infectious diseases</a> can be worsened by climate change.</p>
<p>Flooding, for example, can affect water quality and the habitats where dangerous bacteria and vectors like mosquitoes can breed and transmit infectious diseases to people.</p>
<p>Dengue, a painful mosquito-borne viral disease that sickens <a href="https://www.cdc.gov/dengue/about/index.html">about 100 million</a> people a year, becomes more common in warm, wet environments. Its R0, or basic reproduction number – a gauge of how quickly it spreads – <a href="https://doi.org/10.1016/S0140-6736(22)01540-9">increased by about 12%</a> from the 1950s to the average in 2012-2021, according to the 2022 Lancet Countdown report. Malaria’s season expanded by 31% in highland areas of Latin America and nearly 14% in Africa’s highlands as temperatures rose over the same period.</p>
<figure class="align-center ">
<img alt="Rows of beds, some covered with mosquito nets, fill a warehouse-like space. Doctors visit with some of the patients." src="https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493916/original/file-20221107-19-5r15ur.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients rest in a makeshift dengue ward at a hospital during a severe outbreak in Pakistan in 2021.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/patients-take-rest-on-beds-arranged-inside-a-makeshift-news-photo/1235932771">Arif Ali/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Flooding can also spread waterborne organisms that cause <a href="https://doi.org/10.1186/s12879-020-04961-4">hepatitis</a> and <a href="https://doi.org/10.1136/bmj.39503.700903.DB">diarrheal diseases</a>, such as cholera, particularly when large numbers of people are displaced by disasters and living in areas with poor water quality for drinking or washing. </p>
<p><a href="https://doi.org/10.1371/currents.dis.7a2cee9e980f91ad7697b570bcc4b004">Droughts</a>, too, can degrade drinking water quality. As a result, more rodent populations enter into human communities in search of food, increasing the <a href="https://doi.org/10.3390/pathogens11010015">potential to spread hantavirus</a>.</p>
<h2>Extreme heat</h2>
<p>Another serious health risk is rising temperatures. </p>
<p>Excessive heat can <a href="https://www.who.int/news-room/fact-sheets/detail/climate-change-heat-and-health">exacerbate existing health problems</a>, such as <a href="https://doi.org/10.1111/all.14177">cardiovascular</a> and respiratory diseases. And when heat stress becomes <a href="https://www.cdc.gov/niosh/topics/heatstress/heatrelillness.html">heat stroke</a>, it can <a href="https://www.mayoclinic.org/diseases-conditions/heat-stroke/symptoms-causes/syc-20353581">damage the heart, brain and kidneys</a> and become lethal.</p>
<p>Today, about 30% of the global population is exposed to potentially deadly heat stress each year. The Intergovernmental Panel on Climate Change estimates that percentage will rise <a href="https://www.ipcc.ch/report/ar6/wg2/about/frequently-asked-questions/keyfaq3/">to at least 48% and as high as 76%</a> by the end of this century.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=477&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=477&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=477&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=599&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=599&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493119/original/file-20221102-24-un18ln.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=599&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Where climate change affects human health.</span>
<span class="attribution"><span class="source">Centers for Disease Control and Prevention</span></span>
</figcaption>
</figure>
<p>In addition to lives lost, heat exposure was projected to have resulted in <a href="https://www.thelancet.com/infographics-do/climate-countdown-2022">470 billion potential work hours lost</a> globally in 2021, with associated income losses totaling up to US$669 billion. As populations grow and heat rises, more people will be relying on air conditioning powered by fossil fuels, which <a href="https://www.iea.org/news/air-conditioning-use-emerges-as-one-of-the-key-drivers-of-global-electricity-demand-growth">further contributes to climate change</a>.</p>
<h2>Food and water security</h2>
<p>Heat also affects food and water security for a growing population.</p>
<p>The Lancet review found that high temperatures in 2021 <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01540-9/fulltext">shortened the growing season</a> by about 9.3 days on average for corn, or maize, and six days for wheat compared with the 1981-2020 average. Warming oceans, meanwhile, can kill shellfish and shift <a href="https://doi.org/10.1111/gcb.14512">fisheries that coastal communities rely on</a>. Heat waves in 2020 alone resulted in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01540-9/fulltext">98 million more</a> people facing food insecurity compared with the 1981-2010 average.</p>
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<img alt="A woman standing in a field examines a stalk of sorghum" src="https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493915/original/file-20221107-21-i2g9p0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A farmer in Zimbabwe switched to sorghum, a grain crop that can thrive in dry conditions, as drought withered other crops in 2019.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/angeline-kadiki-an-elderly-who-is-a-sorghum-farmer-inspects-news-photo/1130994283">Jekesai Njikizana/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Rising temperatures also affect fresh water supplies through evaporation and by shrinking <a href="https://e360.yale.edu/features/andes-meltdown-new-insights-into-rapidly-retreating-glaciers">mountain glaciers</a> and <a href="https://www.ioes.ucla.edu/project/climate-change-sierra-nevada/">snowpack</a> that historically have kept water flowing through the summer months.</p>
<p>Water scarcity and drought have the potential to displace almost <a href="https://unstats.un.org/sdgs/report/2022/goal-13/">700 million people by 2030</a>, according to U.N. estimates. Combined with population growth and growing energy needs, they can also fuel geopolitical conflicts as countries face food shortages and compete for water.</p>
<h2>Poor air quality</h2>
<p>Air pollution can be <a href="https://theconversation.com/extreme-heat-air-pollution-can-be-deadly-with-the-health-risk-together-worse-than-either-alone-187422">exacerbated by the drivers of climate change</a>. Hot weather and the same fossil fuel gases warming the planet <a href="https://www.lung.org/clean-air/climate-change/climate-change-air-pollution">contribute to ground-level ozone</a>, a key component of smog. That can exacerbate allergies, asthma and other respiratory problems, as well as cardiovascular disease. </p>
<p>Wildfires fueled by hot, dry landscapes <a href="https://doi.org/10.1126/sciadv.abi9386">add to the air pollution health risk</a>. Wildfire smoke is laden with tiny particles that can travel deep into the lungs, <a href="https://www.epa.gov/wildfire-smoke-course/why-wildfire-smoke-health-concern">causing heart and respiratory problems</a>. </p>
<figure class="align-center ">
<img alt="Three school girls with backpacks walk through smog along a road while covering their mouths with handkerchiefs." src="https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/493917/original/file-20221107-25-5gvhig.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Smog in New Delhi, India, is an ongoing problem. It got so bad in 2017 that the city temporarily closed its primary schools.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/indian-schoolchildren-cover-their-faces-as-they-walk-to-news-photo/871511920">Sajjad Hussain/AFP via Getty Images</a></span>
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<h2>What can we do about it?</h2>
<p>Many groups and medical experts are working to counter this cascade of negative climate consequences on human health.</p>
<p>The U.S. National Academy of Medicine has embarked on an ambitious <a href="https://nam.edu/programs/climate-change-and-human-health/">grand challenge in climate change, human health, and equity</a> to ramp up research. At many academic institutions, including the University of Pittsburgh’s School of Public Health, where I am dean, climate and health are being embedded in research, teaching and service.</p>
<p>Addressing the health burden on low- and middle-income countries is pivotal. Often, the <a href="https://www.ncbi.nlm.nih.gov/books/NBK525226/">most vulnerable</a> people in these countries <a href="https://sdgs.un.org/goals/goal13">face the greatest harms from climate change</a> without having the resources to protect their health and environment. Population growth can <a href="https://doi.org/10.1289/EHP10384">deepen these iniquities</a>. </p>
<p><a href="https://www.paho.org/en/news/19-8-2022-eu-and-paho-supporting-nine-caribbean-countries-integration-health-national">Adaptation assessments</a> can help high-risk countries prepare for the effects of climate change. Development groups are also leading projects to <a href="https://www.cgiar.org/">expand the cultivation of crops</a> that can thrive in dry conditions. The <a href="https://www.paho.org/en">Pan American Health Organization</a>, which focuses on the Caribbean, is an example of how countries are working to reduce communicable diseases and advance regional capacity to counter the impact of climate change.</p>
<p>Ultimately, reducing the health risks will require <a href="https://www.unep.org/resources/emissions-gap-report-2022">reducing the greenhouse gas emissions</a> that are driving climate change. </p>
<p>Countries worldwide <a href="https://unfccc.int/process/the-convention/history-of-the-convention#Essential-background">committed in 1992</a> to reduce greenhouse gas emissions. Thirty years later, global emissions are <a href="https://www.unep.org/events/publication-launch/emissions-gap-report-2022">only beginning to flatten</a>, and communities around the world are increasingly suffering extreme heat waves and devastating floods and droughts.</p>
<p>The <a href="https://unfccc.int/event/cop-27">U.N. climate change talks</a>, which in my view aren’t focusing enough on health, can help bring attention to key climate impacts that harm health. As U.N. Secretary-General António Guterres noted: While we celebrate our advances, “at the same time, it is a reminder of our shared responsibility to care for our planet and a moment to reflect on where we still fall short of our commitments to one another.”</p>
<p><em>Samantha Totoni, a Ph.D. candidate at the University of Pittsburgh School of Public Health, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/193077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Lichtveld does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The human population has doubled in 48 years, and worsening climate change has left the world facing serious health risks, from infectious diseases to hunger and heat stress.Maureen Lichtveld, Dean of the School of Public Health, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1933992022-11-04T06:57:52Z2022-11-04T06:57:52ZMalaria in Africa: why most countries haven’t beaten it yet<figure><img src="https://images.theconversation.com/files/492516/original/file-20221031-21-j9vutx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">80% of malaria deaths are in children younger than five. </span> <span class="attribution"><span class="source">Olympia de Maismont/AFP via Getty Images</span></span></figcaption></figure><p>Malaria remains one of the most devastating parasitic diseases affecting humans. In 2020 there were around 241 million cases and 672,000 malaria-related deaths. This is a sharp <a href="https://www.who.int/publications/i/item/9789240040496">increase</a> from 2019. </p>
<p>One reason it’s so persistent is that the malaria parasite has a very <a href="https://www.cdc.gov/malaria/about/biology/index.html#:%7E:text=The%20malaria%20parasite%20life%20cycle,which%20rupture%20and%20release%20merozoites%20">complex life cycle</a>. It involves many different developmental stages and multiple hosts (mosquitoes and humans). </p>
<p>And in Africa, what adds to the challenge of controlling malaria is that the continent is home to some of the most <a href="https://apps.who.int/iris/bitstream/handle/10665/310862/9789241550499-eng.pdf">efficient malaria vectors</a>. These include <em>Anopheles gambiae</em> and <em>An. funestus</em>. Also, the malaria parasite species <em>Plasmodium falciparum</em>, the <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">dominant species</a> in Africa, is the most lethal. It’s responsible for most malaria cases and deaths – 80% of which occur in children younger than five. </p>
<p>The World Health Organization (WHO) acknowledged these factors when it excluded Africa from its first Global Malaria Eradication Campaign, which ran <a href="https://www.cdc.gov/malaria/about/history/">from 1955 until 1969</a>.</p>
<p>Since then, there have been many advances in malaria control. These include long-lasting insecticide treated nets, malaria rapid diagnostic tests and artemisinin-based combination therapies (ACTs) for malaria treatment. </p>
<p>But malaria elimination is still a challenge. Only <a href="https://www.who.int/teams/global-malaria-programme/elimination/countries-and-territories-certified-malaria-free-by-who">two African countries</a>, Algeria and Morocco, have been certified malaria-free by the WHO. </p>
<p>There are many reasons for the elimination targets remaining out of reach. In this article we highlight four: poverty, human movement, resistance and climate change.</p>
<h2>Poverty</h2>
<p>The limited progress towards malaria elimination is not surprising considering that some of the most malaria-burdened countries in Africa are also some of <a href="https://www.malariaconsortium.org/userfiles/file/Past%20events/factsheet2%20-%20malaria%20and%20poverty.pdf">the poorest countries</a> in the world.</p>
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Read more:
<a href="https://theconversation.com/ending-malaria-in-africa-needs-to-focus-on-poverty-quick-fixes-wont-cut-it-169205">Ending malaria in Africa needs to focus on poverty: quick fixes won't cut it</a>
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<p>Malaria is both a cause and a consequence of poverty. The disease will therefore remain a significant problem in Africa, if more is not done to improve the socio-economic status of malaria-affected communities. Eliminating poverty to improve the health and well-being of all are part of both the <a href="https://www.un.org/millenniumgoals/">millennium</a> and <a href="https://sdgs.un.org/goals">sustainable</a> development goals. This should be a priority for governments of malaria-endemic countries.</p>
<h2>Mobility</h2>
<p>Africa has one of the fastest growing populations, with a <a href="https://www.migrationpolicy.org/article/africa-intracontinental-free-movement#:%7E:text=The%20African%20continent%20has%20the,region%20is%20growing%20even%20faster">high level of mobility</a>. Marginalised and vulnerable populations are some of most mobile groups within Africa. They travel vast distances across countries with varying malaria transmission intensities. </p>
<p>Human mobility is strongly associated with the global <a href="https://www.gavi.org/vaccineswork/5-reasons-why-pandemics-like-covid-19-are-becoming-more-likely">spread of infectious diseases</a>, as demonstrated by the recent COVID-19, Ebola and monkeypox outbreaks. This presents a challenge to Africa’s malaria elimination aspirations. </p>
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Read more:
<a href="https://theconversation.com/how-africas-porous-borders-make-it-difficult-to-contain-ebola-118719">How Africa's porous borders make it difficult to contain Ebola</a>
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<p>Malaria parasites and mosquitoes do not respect country borders, so malaria services must expand to mobile and marginalised populations. Universal access to effective malaria diagnostics and treatment will reduce the malaria burden by decreasing onward transmission.</p>
<h2>Resistance</h2>
<p>One of the biggest threats to eliminating and eradicating malaria is the <a href="https://www.who.int/news-room/fact-sheets/detail/malaria#:%7E:text=Progress%20in%20global%20malaria%20control,to%20insecticides%20among%20Anopheles%20mosquitoes">emergence and spread</a> of insecticide, diagnostic and drug resistance. </p>
<p>Both the malaria vectors and parasites have proved to be very adaptable. They have rapidly developed mechanisms to survive and multiply in the presence of insecticides and antimalarial drugs, respectively. </p>
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Read more:
<a href="https://theconversation.com/some-malaria-parasites-are-evading-detection-tests-causing-an-urgent-threat-to-public-health-177258">Some malaria parasites are evading detection tests, causing an urgent threat to public health</a>
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<p>Insecticide resistance is widespread across the <a href="https://www.bdi.ox.ac.uk/news/tracking-the-spread-of-mosquito-insecticide-resistance-across-africa">African region</a>. It reduces the efficacy of strategies based on suppressing vectors, such as long-lasting insecticide treated nets and indoor residual spraying. </p>
<p>To extend the effective lifespan of the available insecticides, the WHO has provided <a href="http://apps.who.int/iris/bitstream/handle/10665/44768/9789241502801_eng.pdf;jsessionid=233E06F6978781E9163F1479ED99F9F7?sequence=1">new guidance</a> in its handbook for integrated vector management. The handbook highlights the importance of routine entomological surveillance to determine the type of vectors present, changes in vector behaviour and the insecticide susceptibility status of the vector. All this information can guide effective vector suppression if available in good time. </p>
<p>Having the correct diagnostic method and treatment in place also hinges on having a robust surveillance system. The system must be capable of generating efficacy data in near real-time to allow for prompt evidence-based decision-making. The need for this type of <a href="https://www.who.int/news/item/28-05-2021-statement-by-the-malaria-policy-advisory-group-on-the-urgent-need-to-address-the-high-prevalence-of-pfhrp2-3-gene-deletions-in-the-horn-of-africa-and-beyond">routine surveillance</a> has become even more urgent as African malaria parasites have developed mutations that allow them to evade detection by the most widely used rapid diagnostic tests on the continent. These undetected cases will go untreated, potentially sustaining onward transmission. The result will be major increases in malaria cases, severe disease, and potentially death.</p>
<p>Besides becoming invisible to rapid diagnostic tests, <em>P. falciparum</em> parasites in many central and west African countries have become <a href="https://www.npr.org/sections/goatsandsoda/2022/02/06/1077953012/drug-resistant-malaria-is-emerging-in-africa-doctors-are-worried-yet-hopeful">resistant</a> to artemisinins. This is a component of the most widely used antimalarials in Africa, ACTs. The spread of artemisinin-resistant parasites will potentially raise case numbers and deaths, repeating the devastating trend observed when drug-resistant parasites previously emerged. The loss of ACTs would severely set back elimination efforts as there are no novel WHO-approved antimalarials currently available. Efforts are needed to prevent the spread of artemisinin-resistant parasites through strong surveillance and containment responses.</p>
<h2>Climate change</h2>
<p>The impact of climate change is complex, but there are <a href="https://www.un.org/en/chronicle/article/climate-change-and-malaria-complex-relationship#:%7E:text=An%20increase%20in%20temperature%2C%20rainfall,it%20was%20not%20reported%20earlier">suggestions</a> that more places will become malaria risk areas. Mosquitoes will now be able to survive and transmit malaria in these warmer areas. This, in turn, will increase malaria cases, severe illness and deaths in the non-immune communities.</p>
<h2>Positive developments</h2>
<p>In spite of these challenges, there is some light at the end of tunnel. </p>
<p>After years of research there are two new malaria vaccines. The first, <a href="https://www.gsk.com/en-gb/media/press-releases/who-grants-prequalification-to-gsk-s-mosquirix-the-first-and-only-approved-malaria-vaccine/">Mosquirix</a>, has been prequalified for use by the WHO. The second, <a href="https://www.medicalnewstoday.com/articles/malaria-new-vaccine-candidate-shows-promise-in-clinical-trials">R21/Matrix M</a>, has shown promising results in phase 2 clinical trials. </p>
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Read more:
<a href="https://theconversation.com/vaccines-could-be-a-game-changer-in-the-fight-against-malaria-in-africa-193233">Vaccines could be a game-changer in the fight against malaria in Africa</a>
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<p>There are new long-lasting insecticide treated nets and insecticide formulations for vector control. There are also novel strategies for parasite suppression. </p>
<p>Adding these tools to the elimination toolbox will assist Africa get closer to malaria elimination.</p><img src="https://counter.theconversation.com/content/193399/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jaishree Raman is affiliated with the National Institute for Communicable Diseases, the Wits Research Institute for Malaria and UP Institute for Sustainable Malaria Control. She received funding from the South African Research Trust, South African Medical Research Council, Bill and Melinda Gates Foundation, the Global Fund, Clinton Health Access Initiative, National Research Foundation and the National Institute for Communicable Diseases</span></em></p><p class="fine-print"><em><span>Shüné Oliver s affiliated with the National Institute for Communicable Diseases and the Wits Research Institute for Malaria and receives funding from the National Research Foundation, the National Health Laboratory Services Research Trust and the Female Academic Leadership fund. </span></em></p>There are many reasons that malaria is so persistent in Africa. Four of them are poverty, human movement, resistance and climate change.Jaishree Raman, Principal Medical Scientist and Head of Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research, National Institute for Communicable DiseasesShüné Oliver, Medical scientist, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1932402022-11-03T13:46:52Z2022-11-03T13:46:52ZClimate change: the effects of extreme heat on health in Africa – 4 essential reads<figure><img src="https://images.theconversation.com/files/492993/original/file-20221102-22-59h8xy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Scientists are sounding the <a href="https://www.unicef.org/reports/coldest-year-rest-of-their-lives-children-heatwaves">alarm</a> about the extreme increases in the Earth’s temperature. A new report by UNICEF <a href="https://www.unicef.org/media/129506/file/UNICEF-coldest-year-heatwaves-and-children-EN.pdf">warns</a> that 2022 could be the “coldest year of the rest of our lives”. Heatwaves are becoming stronger and lasting longer. These increases are threatening the limits of human survival. </p>
<p>The African continent is particularly at risk – it’s heating up <a href="https://unfccc.int/news/climate-change-is-an-increasing-threat-to-africa">more</a>, and faster, than any other region in the world. By 2030, up to <a href="https://www.uneca.org/stories/state-of-climate-in-africa-report-2020">118 million extremely poor people</a> in Africa will be subject to the devastating impacts of drought and intense heat. This has huge implications for human health, from the spread of disease to heat stress. </p>
<p>Experts writing for The Conversation Africa have explored these issues in a number of articles. We’ve collected four of these important reads here.</p>
<h2>1. Surviving extreme heat</h2>
<p>The general limit of heat we should live in is 35°C wet-bulb temperature, which is a measure of both air temperature and humidity. Beyond this, the body struggles to cool itself. </p>
<p>Extreme heat is a serious health hazard. Many of the temperatures being recorded in Africa now, and those projected for the next decade, are already close to the limits of human survival, or “liveability”.</p>
<p>Health experts Abdu Mohiddin, Christopher Jack, Evans Kituyi, Kristie Ebi, Matthew Chersich and Stanley Luchters provide insights into who’s most at risk from extreme heat, and what must be done to mitigate it.</p>
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<a href="https://theconversation.com/extreme-heat-hurts-human-health-its-effects-must-be-mitigated-urgently-171327">Extreme heat hurts human health. Its effects must be mitigated -- urgently</a>
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<h2>2. Vulnerable living spaces</h2>
<p>Cities are recognised as areas particularly vulnerable to the effects of heat on health. This is because urbanised areas experience higher temperatures than less-urbanised or rural areas. </p>
<p>Within cities, people living in informal settlements are particularly at risk of increased temperatures. Lorena Pasquini, a climate change adaptation researcher, <a href="https://theconversation.com/heat-and-health-dar-es-salaams-informal-settlements-need-help-181816">reveals</a> why. She carried out research in informal settlements in Tanzania’s capital, Dar es Salaam, and explains that the structures people live in have features that either increase temperatures or lack features that would cool them down. </p>
<p>In addition, inadequate or absent planning means that housing is too densely packed so that air can’t circulate.</p>
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Read more:
<a href="https://theconversation.com/heat-and-health-dar-es-salaams-informal-settlements-need-help-181816">Heat and health: Dar es Salaam's informal settlements need help</a>
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<h2>3. Children at risk</h2>
<p>Children, especially newborn babies, are at particular risk of heat stress. This is because they’re less able to control their body temperature. They can easily become dangerously hot or cold.</p>
<p>Climate experts Cathryn Birch, John Marsham and Sarah Chapman <a href="https://theconversation.com/climate-change-will-cause-more-african-children-to-die-from-hot-weather-188609">estimate</a> that between 2011 and 2020, there were between 12,000 and 19,000 heat-related child deaths per year in Africa. </p>
<p>Climate change accounts for about half of these deaths. The additional deaths due to climate change cancel out the recent reduction in heat-related deaths that was achieved through developmental improvements.</p>
<p>This <a href="https://theconversation.com/climate-change-will-cause-more-african-children-to-die-from-hot-weather-188609">research</a> underscores the urgent need to reduce emissions and the impact of heat on babies and children.</p>
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Read more:
<a href="https://theconversation.com/climate-change-will-cause-more-african-children-to-die-from-hot-weather-188609">Climate change will cause more African children to die from hot weather</a>
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<h2>4. Growing risk of mosquito-borne diseases</h2>
<p>Extreme heat can have a <a href="https://www.who.int/news-room/fact-sheets/detail/climate-change-heat-and-health">direct impact</a> on people’s health, for example by causing heat exhaustion or heat strokes. High temperatures also have an indirect impact on health – for example through disease transmission. Researchers have <a href="https://wellcome.org/news/how-climate-change-affects-vector-borne-diseases">warned</a> that climate change will lead to an increase in the number of people exposed to new mosquito-borne diseases. </p>
<p>Mosquitoes are among the deadliest animals in the world. Beyond being annoying, these insects transmit diseases such as malaria, zika virus and yellow fever. </p>
<p>Shüné Oliver, a biochemist, and her colleagues at South Africa’s National Institute for Communicable Diseases have been tracking <em>Anopheles arabiensis</em>, one of the mosquito species that transmits malaria. </p>
<p>Their research shows that insecticide-resistant mosquitoes can withstand extreme heat. This will complicate malaria control.</p>
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Read more:
<a href="https://theconversation.com/how-higher-temperatures-and-pollution-are-affecting-mosquitoes-114768">How higher temperatures and pollution are affecting mosquitoes</a>
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Marginalised or minority groups seem to suffer the most from heat-related deaths and disease.Moina Spooner, Assistant EditorIna Skosana, Health + Medicine Editor (Africa edition)Licensed as Creative Commons – attribution, no derivatives.