World malariareport 2013

2013WORLD MALARIA REPORT WHO GLOBAL MALARIA PROGRAMME

WHO Library Cataloguing-in-Publication Data

World malaria report : 2013.

1.Malaria - prevention and control. 2 Malaria - economics. 3.Malaria - epidemiology. 4.National health programs - utilization. 5.Insecticide-treated bednets. 6.Antimalarials - therapeutic use. 7.Drug resistance. 8.Disease vectors. 9.Malaria vaccines. 10.World health. I.World Health Organization.

ISBN 978 92 4 156469 4 (NLM classifi cation: WC 765)

World Health Organization 2013

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WORLD MALARIA REPORT 2013 | iii

ContentsForeword vAcknowledgements viAbbreviations viiiSummary and Key Points ixAvant-propos xvRsum et points essentiels xviPrefacio xxiResumen y puntos esenciales xxiii

CHAPTER 1 Introduction 1CHAPTER 2 Policies, strategies, goals and targets for malaria control and elimination 3

2.1 Policy development 32.2 Malaria control policies and strategies 42.3 Malaria surveillance 112.4 Malaria elimination 122.5 Goals and targets for malaria control and elimination 122.6 Indicators of progress 12

CHAPTER 3 Financing malaria control 173.1 International fi nancing of malaria control 173.2 Domestic fi nancing of malaria control 183.3 Comparison of resources available and resource requirements 193.4 Distribution of available funding by WHO Region 193.5 Distribution of available funding by disease burden and national income 203.6 Endemic countrys willingness to pay for malaria control 203.7 Conclusions 21

CHAPTER 4 Vector control for malaria 234.1 Need for vector control 234.2 ITN/LLIN policy and implementation 234.3 IRS policy adoption and implementation 264.4 Larval control strategies 284.5 Malaria vector insecticide resistance and the Global Plan for Insecticide Resistance Management 284.6 Conclusions 30

CHAPTER 5 Preventive therapies for malaria 315.1 Need for preventive chemotherapy 315.2 Malaria chemoprevention policies and implementation 315.3 New therapies for malaria prevention 335.4 Conclusions 34

CHAPTER 6 Diagnostic testing and treatment of malaria 376.1 Needs for diagnostic testing and treatment 376.2 Diagnostic testing for malaria 386.3 Treatment of malaria 406.4 Antimalarial drug resistance 446.5 Conclusions 46

CHAPTER 7 Malaria Surveillance 497.1 Introduction 497.2 Indicators derived from routine information systems 497.3 Indicators derived from household surveys 507.4 Conclusions 52

CHAPTER 8 Changes in malaria incidence and mortality 558.1 Introduction 558.2 Progress towards elimination 588.3 Trends in estimated malaria cases and deaths 618.4 Conclusions 66

Regional profi les 69Country profi les 91Annexes 199

If political commitment wanes, the great progress that has been achieved could be undone in some places in a single transmission season.

WORLD MALARIA REPORT 2013 | v

This years World Malaria Report documents remarkable progress in the global ght against malaria, and includes updated burden esti-mates for the 2000-2012 period.

The report shows that increased political commitment and the expansion of global malaria investments since 2000 have led to major gains against this preventable disease, saving an esti-mated 3.3 million lives.

Each year we have a better understanding of global malaria trends and the burden of disease, as measured against the situation in 2000. According to the latest estimates, malaria mortality rates were reduced by about 45% globally and by 49% in the WHO African Region between 2000 and 2012. During the same period, malaria incidence rates declined by 29% around the world, and by 31% in the African Region. These substantial reductions occurred as a result of a major scale-up of vector control interventions, diagnostic testing, and treatment with artemisinin-based combination therapies, or ACTs.

This progress is no cause for complacency. The absolute numbers of malaria cases and deaths are not going down as fast as they could. The disease still took an estimated 627 000 lives in 2012, mostly those of children under ve years of age in Africa. This means 1300 young lives lost to malaria every day a strong reminder that victory over this ancient foe is still a long way o . The fact that so many people are dying from mosquito bites is one of the greatest tragedies of the 21st century.

If political commitment wanes, the great progress that has been achieved could be undone in some places in a single transmis-sion season. In the last few years, we have started seeing the rst signs of a potential slow-down. In 2011 and 2012, the delivery of long-lasting insecticidal nets to endemic countries slowed down and indoor residual spraying programmes levelled o . During this period, malaria mortality rates continued to go down but at a slower pace. In 2013, bednet deliveries picked up again, and the pipeline for next year is even stronger. Nonetheless, even greater e orts will be needed to protect everyone at risk.

As the international community gradually moves towards a post-2015 development agenda, we must not lose sight of what the worlds most vulnerable populations expect from us. The concept of universal health coverage represents both a social value and an approach to health care that generates better health for entire populations, reduces social inequali-ties, and protects people from poverty induced by health-care costs. It is a key concept that is already at the centre of the

global health debate, and also the debate about the next set of development goals. Progress against malaria provides good evidence of the tangible bene ts of population-wide access to life-saving interventions.

The world also needs to stay focused on addressing the global funding gap for malaria prevention and control. The currently available funding is far less than required to reach universal access to malaria interventions. To achieve our goal, we need an accelerated e ort in scaling up vector control tools. We also need to ensure that the most vulnerable groups chil-dren under ve, infants and pregnant women get access to WHO-recommended intermittent preventive therapies, where appropriate. While progress in expanding diagnostic testing and quality-assured treatment has been immense in recent years, we are far from achieving universal access.

In addition, parasite resistance to artemisinin the core compound in the worlds most e ective antimalarial medi-cines and mosquito resistance to insecticides remain major concerns. If not addressed with appropriate urgency, they could threaten the remarkable progress made since 2000. Though WHO has issued global strategies to tackle these challenges, progress in their adoption by countries has been slow, primarily due to inadequate nancing. In April 2013, on World Malaria Day, WHO launched an Emergency response to artemisinin resis-tance in the Greater Mekong subregion to guide countries in the scale-up and implementation of e orts to eliminate resistant parasites. The funding gap for this e ort is also substantial.

Strengthening health infrastructures, vital registration and surveillance systems is equally critical to further progress. Based on reported data, 59 countries are meeting the MDG target of reversing the incidence of malaria, and 52 countries are on track to reduce their malaria case incidence rates by 75%, in line with World Health Assembly and Roll Back Malaria targets for 2015. However, these 52 countries account for only 4%, or eight million, of the total estimated malaria cases around the world. In 41 endemic countries, including most high-burden coun-tries, we cannot make a reliable assessment of malaria trends. A concerted e ort to improve surveillance systems is needed to remove this gap in our understanding of the malaria situation.

WHO is grateful for the commitment of ministries of health in endemic countries and their many development partners. We are con dent that, if we remain determined and act with urgency, we can beat this ancient enemy once and for all.

ForewordDr Margaret ChanDirector-GeneralWorld Health Organization

vi | WORLD MALARIA REPORT 2013

We are very grateful to the numerous people who contributed to the production of the World malaria report 2013. The following people collected and reviewed data from malaria endemic countries:

Ahmad Walid Sediqi, Ahmad Mureed Muradi and Sami Nahzat(Afghanistan); Hammadi Djamila (Algeria); Nilton Saraiva and Yava L. Ricardo (Angola); Mario Zaidenberg (Argentina); Viktor Gasimov (Azerbaijan); Mannan A. Bangali and Mohammad Jahirul Karim (Bangladesh); Kim Bautista (Belize); Mariam Ok-Sopoh (Benin); Pema Samup, Rinzin Namgay and Sonam Gyeltshen (Bhutan); Marcos Ysrael Fernandez Encinas (Bolivia [Plurinational State of ]); Simon Chihanga (Botswana); Mariana Pereira de Arajo and Poliana de Brito Ribeiro (Brazil); Patrice A. Combary (Burkina Faso); Mbanye Hypax (Burundi); Jlio Monteiro Roigues (Cabo Verde); Abdur Rashid, Siv Sovannaroth and Samphornarann Top (Cambodia); Kouambeng Celestin (Cameroon); Mbary Siolo Mada Bebelou (Central African Republic); Mahamat Iiss Djaskano (Chad); Shaosen Zhang and Yang Man Ni (China); Pablo Enrique, Chaparro Narvez and Nohora Gonzalez (Colombia); Asta eva Marina (Comoros); Youndouka Jean Mermoz (Congo); Jos Luis F. Garcs (Costa Rica); Tanoh Ma Antoine, Vlhi Nzi Annick Eloi, Ehui Anicet and Parfait Katche (Cte dIvoire); Kim Yun Chol and Shusil Pant (Democratic Peoples Republic of Korea); Joris Losimba Likwela (Democratic Republic of the Congo); Abdoulkader Mohamed Garad and Farah Mohamoud Ahmed (Djibouti); Jose Manuel Puello Montero (Dominican Republic); Enrique Castro Saavedra (Ecuador); Oscar Sorto Rubio (El Salvador); Matilde A. Riloha Rivas (Equatorial Guinea); Selam Mihreteab (Eritrea); Hiwot Solomon Ta ese (Ethiopia); Vanessa Ardillon (French Guiana, France); Abdou Razack Sa ou (Gabon); Adam Jagne Sonko and Momodou Kalleh (Gambia); Merab Iosava (Georgia); Constance Bart Plange, Keziah Malm, Wahjib Mohammed, Ko Oosae and Felicia Owusu-Antwi (Ghana); Adolfo Miranda (Guatemala); Nouman Diakite (Guinea); Paulo Djata (Guinea-Bissau); Reyaud Rahman (Guyana); Darlie Antoine (Haiti); Engels Ilich Banegas Medina (Honduras); G.S. Sonal (India); Anand Joshi, Asik Surya and Elvieda Sariwati (Indonesia); Leyla Faraji and Ahmad Raeisi (Iran [Islamic Republic of ]); Muthana Ibrahim Abdul Kareem (Iraq); Rebecca Kiptui (Kenya); Nurbolot Usenbaev (Kyrgyzstan); Deyer Gopinath and Khamsouane Khamsy (Lao Peoples Democratic Republic); Oliver J. Pratt (Liberia); Andry Joeliarijaona Rakotorahalahy (Madagascar); Misheck Luhanga (Malawi); Chun Paul Soo and Mohammed a zi Bin Abdul Hamid (Malaysia); Diakalia Kone (Mali); Ba Mamadou Dit Dialaw and Mohamed Lemine Ould Khary (Mauritania); Hctor Olgun Bernal (Mexico); Graa Matsinhe (Mozambique); Gawrie Nirdoshi Loku Galappaththy, Krongthong Thimasarn and Thar Tun Kyaw (Myanmar); Mwalenga Henina Nghipumbwa (Namibia); Garib Das Thakur and Prakash Ghimire (Nepal); Rolando Francisco Lopez Ampie (Nicaragua); Hadiza Jackou (Niger); Nnenna Ezeigwe (Nigeria); Muhammad Suleman Memon and Qutbuddin Kaka (Pakistan); Ral Medina (Panama); Leo Makita

and Walter Kazadi-Mulombo (Papua New Guinea); Elizabeth Ferreira, Martha Torales and Cynthia Viveros (Paraguay); Maximo Manuel Espinoza Silva (Peru); Mario Baquilod (Philippines); Lasse Vestergaard and Jeunessa Sto Nino (Philippines); Lee Dong-Woo (Republic of Korea); Rukundo Alphonse and Corine Karema (Rwanda); Herodes do Sacramento Rompo (Sao Tome and Principe); Mohammed Hassan Al-Zahrani (Saudi Arabia); Mady Ba, Alioune Badara Gueye, Mdoune Ndiop and Bacary Sambou (Senegal); Thomas K. Ansumana (Sierra Leone); Albi Bobogare, Hugo Borugo, Erick Hale and Baakai Kamoriki (Solomon Islands); Fahim Yusuf and Jamal Amran (Somalia); Devan and Moonasar (South Africa); Harriet Pasquale (South Sudan); Risintha Premaratne and S. L. Deniyage (Sri Lanka); Abd Alla Ahmed Ibrahim Mohd (Sudan); B. Jubithana (Suriname); Sicelo Kunene (Swaziland); Anna Mahendeka (United Republic of Tanzania, Mainland); Abdul-wahid H. Al-mafazy (United Republic of Tanzania, Zanzibar); Sayfuddin Karimov (Tajikistan); Prayuth Sudathip (Thailand); Manel Yapabandara, Maria Mota and Maria do Rosario de Fatima Mota (Timor-Leste); Tchassama Tchadjobo (Togo); Maria Cristina Pro li, Mehmet Kontas and Seher Topluoglu (Turkey); Peter Okui (Uganda); Inna Tyo, Svetlana Tsay and Natalya Lebedeva (Uzbekistan); Wesley Donald (Vanuatu); Jean-Olivier Guintran and Seyha Ros (Vanuatu); Nuncio Nelson Pizzo (Venezuela [Bolivarian Republic of ]); Dai Tran Cong and Nguyen Quy Anh (Viet Nam); Adel Nasser Aljasari and Moamer Badi (Yemen); Sabine Henry and Betty Zumbo (Mayotte); Pags Frdric (France [Runion]); Freddie Masaninga, Ingwe Masaninga and Mercy Mwanza (Zambia); Wonder Sithole (Zimbabwe).

The following WHO sta in regional and subregional o ces assisted in the design of data collection forms; the collection and validation of data; and the review of epidemiological esti-mates, country pro les, regional pro les and chapters:

Boniface Ekoue Kinvi, Etienne Magloire Minkoulou, Georges Alfred Ki-Zerbo and Issa Sanou (WHO Regional O ce for Africa [AFRO]); Spes Ntabangana (AFRO/Inter-country Support Team [IST] Central Africa); Khoti Gausi (AFRO/IST East and Southern Africa); Abderrahmane Kharchi (AFRO/IST West Africa); Keith Carter, Rainier Escalada, Maria Paz Ade and Prabhjot Singh (WHO Regional O ce for the Americas [AMRO]); Amir Aman, Hoda Atta and Ghasem Zamani (WHO Regional O ce for the Eastern Mediterranean [EMRO]); Mikhail Ejov, Elkhan Gasimov and Karen Taksoe-Vester (WHO Regional O ce for Europe [EURO]); Leonard Icutanim Ortega and Rakesh Rastogi (WHO Regional O ce for South-East Asia[SEARO]); Eva-Maria Christophel, Bayo Fatunmbi and Raymond Mendoza (WHO Regional O ce for the Western Paci c[WPRO]).

Dejan Loncar (Global Fund) assisted in the preparation of Chapter 3 (on nancing), and David Pigott (Malaria Atlas Project, University of Oxford) shared data and guidance on its use. Silas Holland, Jurate Juskaite and Melisse Murray (Global Fund) supplied information on nancial disbursements from the Global Fund and the A ordable Medicines Facility for Malaria.

Acknowledgements

WORLD MALARIA REPORT 2013 | vii

For Chapter 4 (on vector control), Abraham Flaxman (Institute for Health Metrics and Evaluation) produced estimates of insec-ticide-treated mosquito net (ITN) coverage for African countries using data from household surveys, ITN deliveries by manufac-turers, ITNs distributed by national malaria control programmes (NMCPs), and ITN coverage indicators.

John Milliner (Milliner Global Associates) provided information on long-lasting insecticidal nets (LLINs) delivered by manu-facturers. Katherine Theiss-Nyland (London School of Hygiene and Tropical Medicine) assessed distribution of ITNs through di erent channels. Erica Kufa helped to prepare data on inter-vention coverage. For chapter 6 (on malaria diagnosis and treatment), Adam Bennett and Thom Eisele (Tulane University) produced estimates of malaria treatment from household surveys. For Chapter 7, Liliana Carvajal and Holly Newby (United Nations Childrens Fund), and Lia Florey (DHS MEASURE) assisted in compiling an inventory of household surveys. For Chapter 8, Ros Howes (Malaria Atlas Project, University of Oxford), Nick Ansty (Menzies School of Health Research, Darwin) and Kevin Baird (Eijkman-Oxford Clinical Research Unit, Jakarata) assisted in the preparation of boxes on Plasmodium vivax. Li Liu (Johns Hopkins Bloomberg School of Public Health), Dan Hogan and Colin Mathers (Department of Health Statistics and Information Systems ,WHO) prepared malaria mortality estimates in children under 5 years of age on behalf of the Child Health Epidemiology Reference Group.

Maps of parasite prevalence for the WHO African Region were produced by Peter Gething, Simon Hay, Andrew Henry and Catherine Moyes of the Malaria Atlas Project at the University of Oxford, with the support of the Wellcome Trust, and with assis-tance from Caroline Kabaria, Abdisalan Noor and Robert Snow of the Malaria Atlas Project (Africa). Paprika (Annecy, France) produced map layouts. Soce Fall (WHO Mali) provided helpful comments on Chapters 4 and 5.

We are also grateful to:

Larry Slutsker (Centers for Disease Control and Prevention) and Melanie Renshaw (African Leaders Malaria Alliance) who graciously reviewed all chapters and provided substantial comments for their formulation;

Yehenew Walilegne (WHO) for legal review;

Renata Cabrera and Bndicte Guery-Morand for the translation of the foreword, summary and key points;

Mar Velarde Rodrguez (ISGlobal) for reviewing chapters and providing programmatic support for overall management of the project;

Claude Cardot and the Designisgood team for the design and layout of the report; and

Hilary Cadman and the Cadman Editing Services team for tech-nical editing of the report.

The World malaria report 2013 was produced by Kathryn Andrews, Maru Aregawi, Richard Cibulskis, Cristin Fergus, Michael

Lynch, Robert Newman, Zso a Szilagyi and Ryan Williams on behalf of the WHO Global Malaria Programme. We are grateful to our colleagues in the Global Malaria Programme who also contributed to the production of chapters: Amy Barrette, Andrea Bosman, Jane Cunningham, Michael MacDonald, Rossitza Mintcheva, Abraham Mnzava, Peter Olumese, Franco Pagnoni, Charlotte Rasmussen, Aafj e Rietveld, Pascal Ringwald, Vasee Sathiyamoorthy and Silvia Schwarte. We also thank Simone Colairo-Valerio, Anne Damnon and Eva Kakyomya for adminis-trative support.

Funding for the production of this report was gratefully received from the Government of Japan, the Norwegian Agency for Development Cooperation and the United Kingdom Department for International Development.

We also thank the Government of Monaco for its program on Accelerated Malaria Control towards Pre-elimination in East and Southern Africa by 2015, which supported collection of malaria programme data

viii | WORLD MALARIA REPORT 2013

AbbreviationsABER annual blood examination rateACD active case detectionACT artemisinin-based combination therapyAIDS acquired immunode ciency syndromeAL artemether-lumefantrineALMA African Leaders Malaria AllianceAMFm A ordable Medicine FacilitymalariaAMP Alliance for Malaria PreventionANC antenatal careANVR Africa Network for Vector ResistanceAPI annual parasite indexAQ amodiaquineAT atovaquoneARDS acute respiratory distress syndromeAusAID Australian Agency for International DevelopmentCDC US Centers for Disease Control and PreventionCFR case fatality rateCHAI Clinton Health Access InitiativeCIDA Canadian International Development AgencyCS circumsporozoiteDDT dichloro-diphenyl-trichloroethaneDFID The United Kingdom Department for

International DevelopmentDHS demographic and health surveyDIPI domestic investment priority indexDTP diphtheriatetanuspertussisE8 Elimination EightEPI Expanded Programme on ImmunizationERAR Emergency response to artemisinin resistance in

the Greater Mekong subregionERG expert review group (but evidence review group

in 2013 report)FIND Foundation for Innovative New DiagnosticsG6PD glucose-6-phosphate dehydrogenaseGlobal Fund The Global Fund to Fight AIDS, Tuberculosis and

MalariaGMAP Global Malaria Action PlanGMP Global Malaria Programme, WHOGNI gross national incomeGPARC Global Plan for Artemisinin Resistance

ContainmentGPIRM Global Plan for Insecticide ResistanceGSK GlaxoSmithKlineHIV human immunode ciency virusHMIS health management information systemiCCM integrated community case managementIEC information, education and communicationIHME Institute for Health Metrics and EvaluationIM intramuscularIPT intermittent preventive treatmentIPTc intermittent preventive treatment for childrenIPTi intermittent preventive treatment in infantsIPTp intermittent preventive treatment in pregnancyIQR interquartile range IRS indoor residual sprayingISGlobal Barcelona Institute for Global Health

ITN insecticide-treated mosquito netLLIN long-lasting insecticidal netMAP Malaria Atlas ProjectMDG Millennium Development GoalMERG RBM Monitoring and Evaluation Reference GroupMICS multiple indicator cluster surveyMIS malaria indicator surveyMPAC Malaria Policy Advisory CommitteeMVI Malaria Vaccine Initiative, PATH NGO nongovernmental organizationNMCP National malaria control programmeOECD Organisation for Economic Co-operation and

DevelopmentP. Plasmodium PATH Program for Appropriate Technology in Health PCD passive case detectionPMI The United States Presidents Malaria InitiativeQA quality assuranceRAM Rotarians Against MalariaRBM Roll Back MalariaRDT rapid diagnostic testSAGE WHO Strategic Advisory Group of Experts on

ImmunizationSMC seasonal malaria chemopreventionSP sulfadoxine-pyrimethamineSPR slide positivity rateTDR Special Programme for Research and Training in

Tropical DiseasesTEG technical expert groupUNAIDS Joint United Nations Programme on HIV/AIDSUNDP United Nations Development ProgrammeUNICEF United Nations Childrens FundUNSE O ce of the United Nations Special Envoy for

MalariaUSAID United States Agency for International

DevelopmentVCAG Vector Control Advisory GroupWER WHO Weekly Epidemiological RecordWHA World Health AssemblyWHO World Health OrganizationWHOPES WHO Pesticide Evaluation Scheme

Abbreviations of WHO Regions / O cesAFR WHO African RegionAFRO WHO Regional O ce for AfricaAMR WHO Region of the AmericasAMRO WHO Regional O ce for the AmericasEMR WHO Eastern Mediterranean RegionEMRO WHO Regional O ce for the Eastern

MediterraneanEUR WHO European RegionEURO WHO Regional O ce for EuropeSEAR WHO South-East Asia RegionSEARO WHO Regional O ce for South-East AsiaWPR WHO Western Paci c RegionWPRO WHO Regional O ce for the Western Paci c

WORLD MALARIA REPORT 2013 | ix

Summary and Key PointsThe World Malaria Report 2013 summarizes information received from malaria-endemic countries and other sources, and updates the analyses presented in the 2012 report. It highlights the prog-ress made towards the global malaria targets set for 2015, and describes current challenges for global malaria control and elim-ination.

Since 2000, a tremendous expansion in the fi nancing and coverage of malaria control programmes has led to a wide-scale reduction in malaria incidence and mortality. Based on reported data, 59 out of 103 countries that had ongoing malaria trans-mission in 2000 are meeting the Millennium Development Goal (MDG) target of reversing the incidence of malaria. Of these, 52 are on track to meet Roll Back Malaria (RBM) and World Health Assembly targets of reducing malaria case incidence rates by 75% by 2015, including 8 countries of the WHO African Region. In 41 countries it is not possible to assess trends using reported data because of inconsistencies in the completeness of reporting over time, changes in diagnostic practice or health-service use. For these countries, which accounted for 80% of cases in 2000, inferences about malaria trends need to be based on estimates of the malaria case incidence and mortality rates.

Worldwide, between 2000 and 2012, estimated malaria mortality rates fell by 45% in all age groups and by 51% in children under 5 years of age. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria mortality rates are projected to decrease by 56% in all ages, and by 63% in chil-dren under 5 years of age by 2015; this represents substantial progress towards the World Health Assembly target of reducing malaria mortality rates by 75% by 2015.

Modelling suggests that an estimated 3.3 million malaria deaths were averted between 2001 and 2012, and that 69% of these lives saved were in the 10 countries with the highest malaria burden in 2000; thus, progress is being made where it matters most. About 3 million (90%) of the deaths averted between 2001 and 2012 are estimated to be in children under 5 years of age in sub-Saharan Africa. These account for 20% of the 15 million child deaths that are estimated to have been averted in sub-Saharan Africa since 2000 through overall reductions in child mortality rates. Thus, decreases in malaria deaths have contrib-uted substantially to progress towards achieving the target for MDG 4, which is to reduce, by two thirds, the under-5 mortality rate between 1990 and 2015.

Nevertheless, between 2011 and 2012, the pace of decrease in estimated malaria mortality rates slowed. This slowing is partly because the model that is used to estimate malaria deaths in children under 5 years of age in Africa uses insecticide-treated mosquito net (ITN) coverage as an input, and ITN coverage fl at-tened in 20112012 following decreases in funding for malaria control in 2011. In 2012, fi nancing of malaria programmes was estimated to be less than half of the estimated US$ 5.1 billion required globally. Thus, millions of people at risk of malaria still do not have access to interventions such as an ITN, indoor

residual spraying (IRS), diagnostic testing and artemisinin-based combination therapies (ACTs). As a result, an estimated 207 million cases (uncertainty interval, 135287 million) and 627 000 malaria deaths (uncertainty interval, 473 000789 000) are esti-mated to have occurred in 2012. There is an urgent need to increase funding for malaria control and to expand programme coverage, in order to meet international targets for reducing malaria cases and deaths.

Policy developmentSeveral new and updated malaria control policies, operational manuals, plans and initiatives were released in 2013, following meetings of WHOs Malaria Policy Advisory Committee (MPAC).

1. The MPAC, which came into operation in 2012, continued its work in 2013; its mandate is to provide strategic advice and technical input to WHO on all aspects of malaria control and elimination. In accordance with the MPAC recommendations, WHO issued guidance on a range of policy areas, including achieving universal coverage with long-lasting insecticidal nets (LLINs), estimating the longevity of LLINs, and capacity-building in malaria entomology and vector control.

2. Other WHO guidance published in 2013 includes (i) an operational manual for IRS; (ii) an operational manual for larval source management; (iii) test procedures for insecti-cide resistance monitoring in malaria vector mosquitoes; (iv) a fi eld guide on seasonal malaria chemoprevention (SMC); (v) a handbook on the management of severe malaria; (vi) a framework for action to respond to artemisinin resistance in the Greater Mekong subregion; (vii) a fi eld handbook on malaria control in complex emergencies (developed in conjunction with several partner agencies); and (viii) three training manuals.

Financing malaria controlThe total international and domestic funding committed to malaria control was estimated to be US$ 2.5 billion in 2012 substantially less than the amount that will be needed to reach the global targets.

3. International disbursements to malaria-endemic countries have increased markedly, from less than US$ 100 million in 2000 to US$ 1.6 billion in 2011, and an estimated US$ 1.94 billion in 2012 and 1.97 billion in 2013. However, increases in international funding have slowed in recent years, to an average of 4% per year between 2009 and 2013, compared to an average of 43% per year between 2005 and 2009.

4. Reported data suggest that global domestic fi nancing for malaria increased over the period 20052012, from US$ 436 million in 2005 to US$ 522 million in 2012. It is estimated that domestic government malaria spending rose at a rate of 4% per year between 2005 and 2012.

x | WORLD MALARIA REPORT 2013

5. Global resource requirements for malaria control were esti-mated in the 2008 RBM Global Malaria Action Plan (GMAP) to exceed US$ 5.1 billion per year between 2011 and 2020. Combining both domestic and international funds, the resources available for malaria control globally were esti-mated to be US$ 2.5 billion in 2012, leaving a gap of US$ 2.6 billion. Projections of both domestic and international resources available between 2013 and 2016 indicate that total funding for malaria control will reach approximately US$ 2.85 billion between 2014 and 2016, which is substan-tially below the amount required to achieve universal access to malaria interventions.

6. International investments in malaria control have been targeted to countries with higher mortality rates and lower national incomes, particularly those in Africa. However, domestic government investments are highest in wealthier countries and lowest in countries with the highest malaria mortality rates. The low rates of domestic spending in coun-tries with higher disease burdens is principally because these countries have lower national incomes per capita.

7. There is variation in the priority given to malaria control by domestic governments that have similar levels of resource availability. Countries that display greater commitment as measured by a domestic investment priority index showed greater success in reducing malaria case incidence between 2000 and 2012 than did other countries.

Progress in vector controlIn sub-Saharan Africa, the proportion of the population with access to an ITN in their household increased dramatically from 2005 to 2011 but the rate fl attened during the last 2 years, reaching 42% in 2013. Increased deliveries of ITNs during the next 2 years should increase ITN coverage.

Insecticide-treated mosquito nets

8. By 2012, 34 countries in the African Region and 83 coun-tries worldwide had adopted the WHO recommendation to provide ITNs to all persons at risk for malaria. A total of 88 countries, including 39 in Africa, distribute ITNs free of charge.

9. Every year, at least 150 million ITNs are needed to maintain a supply of 450 million ITNs in households over each 3-year period and protect all populations at risk of malaria in sub-Saharan Africa. Between 2004 and 2010, the number of ITNs delivered annually by manufacturers to malaria-endemic countries in sub-Saharan Africa increased from 6 million to 145 million. However, only 92 million ITNs were delivered by manufacturers in 2011, and only 70 million were delivered in 2012. The estimated numbers of ITNs delivered in 2013 (136 million) and nanced by donors for 2014 (approximately 200 million) are close to the number of ITNs required annually to protect all populations at risk. However, even with the increase in yearly deliveries, the projected 3-year total of ITNs delivered in 20122014 (about 400 million) will still be below the minimum number needed to protect all persons at risk of malaria. The appropriate levels of ITN deliveries need to be maintained each year, to ensure the availability of ITNs in

households and access to an ITN for every person at risk of malaria.

10. The percentage of households owning at least one ITN in sub-Saharan Africa is estimated to have risen from 3% in 2000 to 56% in 2012, but declined slightly to 54% in 2013. The proportion of the population with access to an ITN in their household increased during the same period, reaching 42% in 2013. The proportion of the population sleeping under an ITN which represents the population directly protected was estimated to be 36% in 2013.

11. A comparison of the proportion of the population with access to an ITN, and the proportion sleeping under an ITN, suggests that a high percentage (86%) of the popula-tion with access to an ITN actually uses it, indicating that e orts to encourage ITN use have been successful. Lack of availability of nets is the main constraint to increasing the number of at-risk persons sleeping under an ITN.

12. Use of ITNs among vulnerable populations, pregnant women and children under 5 years of age is higher than use among the population as a whole. This indicates that these groups remain protected as countries scale up for universal ITN coverage, and it highlights the need to increase access to ITNs among all persons at risk.

Indoor residual spraying

13. IRS remains a powerful vector control tool for reducing and interrupting malaria transmission. In 2012, a total of 88 coun-tries, including 40 in the African Region, recommended IRS for malaria control.

14. In 2012, 135 million people (4% of the global population at risk of malaria) were protected by IRS worldwide. In the African Region, the proportion of the population at risk that was protected rose from less than 5% in 2005 to 11% in 2010, but fell to 8% in 2012, with 58 million people bene- ting from the intervention. The decrease in the number of people protected by IRS in Africa appears to be partly due to increased use of more costly non-pyrethroid insec-ticides (in response to the threat of insecticide resistance) in a setting of limited IRS budgets. The use of non-pyrethroids for IRS may become increasingly important as a resistance-management tool because all currently approved LLINs are pyrethroid based.

Insecticide resistance

15. Mosquito resistance to at least one insecticide used for malaria control has been identi ed in at least 64 malaria-endemic countries worldwide. In May 2012, WHO and RBM released the Global Plan for Insecticide Resistance Management (GPIRM) in malaria vectors; the GPIRM is a ve-pillar strategy for managing the threat of insecticide resistance. Stakeholders in the global malaria community have begun activities related to implementing the strategy laid out in the GPIRM.

16. Monitoring insecticide resistance is a necessary element of the implementation of insecticide-based vector control inter-ventions. In 2012, a total of 58 countries reported that they had adopted a policy of routine monitoring of insecticide resistance.

WORLD MALARIA REPORT 2013 | xi

Progress on chemopreventionAmong African countries reporting this information to WHO, the median percentage of pregnant women attending antenatal care (ANC) who received at least one dose of intermittent preventive treatment (IPT) during pregnancy in 2012 was 64%, whereas 38% received at least two doses and 23% received at least three doses, indicating that there is considerable scope for improving protection for pregnant women.

17. In sub-Saharan Africa, an estimated 35 million pregnant women and a large portion of the estimated 26 million infants born each year would benefi t from IPT. In addition, about 25 million children in the Sahel subregion of Africa could be protected from malaria through SMC.

18. A total of 36 sub-Saharan African countries with moderate to high malaria transmission had adopted IPT for preg-nant women (IPTp) as national policy by the end of 2012. This policy was also adopted by Papua New Guinea (in the Western Pacifi c Region) in 2009.

19. Among 26 of the 36 moderate to high transmission coun-tries in the African Region that have adopted IPTp as national policy and for which data are available a median of 64% of pregnant women attending ANC received at least one dose of IPTp in 2012, 38% received at least two doses and 23% received at least three doses. In 13 countries in the African Region for which household survey data were avail-able for 20102012, the weighted average of all pregnant women who received one dose of IPTp during pregnancy was 37%, whereas 23% received two doses and 8% received three doses.

20. Since October 2012, WHO has recommended that IPTp be given at each scheduled antenatal visit after the fi rst trimester. Analysis of household survey data reveals that the proportion of pregnant women who receive IPTp is well below the proportion who attend ANC. The estimated proportion of ANC visits in which IPTp could be given but is not is high, at 72%. A lower proportion of women receive IPTp during ANC visits than receive tetanus toxoid (another key component of ANC). This indicates that the capacity to deliver preventive services during ANC visits is high, and that barriers to IPTp can be overcome.

21. All infants at risk of Plasmodium falciparum infection in sub-Saharan African countries with moderate-to-high malaria transmission and low levels of parasite resistance to the recommended agent sulfadoxine-pyrimethamine (SP) should receive preventive malaria treatment through immunization services at defi ned intervals that correspond to routine vaccination schedules. Only one country, Burkina Faso, has adopted a national policy of IPT for infants (IPTi) since the WHO recommendation was issued in 2009.

22. In March 2012, WHO issued a recommendation on SMC for children aged 359 months, and in August 2013, WHO released a fi eld guide for implementation of SMC. Two endemic countries have adopted SMC, and several countries involved in evaluating the policy have indicated that they plan to adopt this policy and expand SMC coverage beyond their study populations.

Progress in diagnostic testing and malaria treatmentThe numbers of procured rapid diagnostic tests (RDTs) and ACTs are increasing, as is the reported rate of diagnostic testing in the public sector in the African Region, which increased from 37% in 2010 to 61% in 2012. As a result, there has been a decrease in the number of suspected malaria cases treated presumptively with antimalarial drugs. However, millions of people with suspected malaria still do not receive a diagnostic test, and many people with confi rmed infections do not receive appropriate treatment with a quality assured antimalarial.

Diagnostic testing

23. Implementation of universal diagnostic testing in the public and private sectors would substantially reduce the global requirements for antimalarial treatment. In 2012, 41 of 44 countries with ongoing malaria transmission in the African Region, and 49 of 55 countries in other WHO regions, reported having adopted a policy of providing parasitolog-ical diagnosis for all age groups. This represents an increase of 6 countries in the African Region since 2009.

24. Malaria diagnostic testing is provided free of charge in the public sector in 85 countries around the world. From 2010 to 2012, the proportion of suspected malaria cases receiving a diagnostic test in the public sector increased from 37% to 61% in the African Region, and from 44% to 64% globally. Most of the increase in testing in the African Region is attrib-utable to increased use of RDTs, which accounted for 40% of all cases tested in the region in 2012.

25. The number of patients tested by microscopic examina-tion increased to a peak of 188 million in 2012, with India accounting for over 120 million blood-slide examinations. The number of RDTs supplied by manufacturers increased from 88 million in 2010 to 205 million in 2012. This included increased sales for both P. falciparum-specifi c tests and combination tests that can detect more than one parasite species.

26. A total of 48 countries reported deployment of RDTs at the community level, and 15 million patients were reported as having been tested through such programmes in 2012. Household survey data from 14 countries collected during 20102012 suggest that diagnostic testing is not as widely available in the private sector as it is in the public sector.

27. RDTs are increasingly used for diagnostic testing of suspected malaria cases in health facilities, including for the diagnosis of P. vivax. Among 42 countries reporting the type of RDTs used, 15 reported deploying RDTs that could detect P. vivax specifi cally. In these countries, the proportion of P. vivax cases confi rmed by RDT (rather than microscopy) was similar to the proportion of P. falciparum cases confi rmed by RDT.

Treatment

28. ACTs are recommended as the fi rst-line treatment of malaria caused by P. falciparum, the most dangerous of the Plasmodium parasites that infect humans. By 2012, 79 coun-tries and territories had adopted ACTs as fi rst-line treatment

xii | WORLD MALARIA REPORT 2013

for P. falciparum malaria. P. vivax malaria should be treated with chloroquine where that drug is e ective, or by an appropriate ACT in areas where P. vivax is resistant to chlo-roquine. Treatment of P. vivax should be combined with a 14-day course of primaquine to prevent relapse.

29. From reports of manufacturers and the A ordable Medicines Facility-malaria (AMFm) initiative, the number of ACT treat-ment courses delivered to the public and private sectors increased from 11 million globally in 2005 to 76 million in 2006, and reached 331 million in 2012. The increases in ACT procurement in routine public sector in 2012 were due primarily to an increase of about 50% in public sector deliv-eries between 2011 to 2012. Drugs procured for the public and private sector through the AMFm initiative which is now in a transitional phase towards eventual integra-tion into the routine grant-making process for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) decreased slightly from 156 million treatment courses in 2011 to 150 million in 2012.

30. It has been di cult to track the extent to which patients with con rmed malaria received antimalarial medicines, because information linking diagnostic testing and treatment has been limited in both household surveys and routine health-information systems. An estimate of the proportion of patients in the public sector potentially treated with ACTs (rather than a less e ective antimalarial) can be made by comparing the number of ACT treatments distributed by national malaria control programmes (NMCPs) with the number of presumed (i.e. treated without testing) and con rmed (i.e. con rmed by microscopy or RDT) cases of P. falciparum malaria (adjusted for reporting completeness or estimated, in situations where reported data are lacking). This proportion varies by WHO region, but has increased over time in the African Region, where it reached 60% in 2012.

31. In nine countries in the African Region with more than one household survey between 2006 and 2012, the proportion of febrile children given antimalarial treatment comprising ACTs increased over time, in both the public and private sectors. In the most recent surveys, the median proportion of children receiving an antimalarial who received an ACT was 68%; however, because a substantial portion of children are not brought for care of fever, and not all children with suspected malaria are given a diagnostic test, the propor-tion of all children with malaria who receive an ACT is likely to be substantially lower. In an analysis of 26 household surveys conducted in 20102012 that used a positive RDT among febrile children as a proxy for con rmed malaria, the mean proportion of all children with con rmed malaria who received an ACT was 16% (range, 1%42%). Increased access to care for fever, as well as appropriate diagnostic testing and therapeutic management at all places of care, is needed to ensure that all patients with malaria receive prompt and e ective treatment.

32. In the African Region in 2012, the total number of tests (both microscopy and RDTs) was almost equal to the number of ACTs distributed by NMCPs an increased ratio compared to previous years. However, in most malaria-endemic areas,

the ratio is expected to exceed 2, because less than half of suspected malaria cases will have con rmed malaria and require treatment with an ACT.

Antimalarial drug resistance33. WHO recommends that oral artemisinin-based mono-

therapies be progressively withdrawn from the market and replaced with ACTs a policy that was endorsed by the World Health Assembly in 2007. The number of countries that still allow the marketing of these products decreased from 55 in 2008 to 9 as of November 2013; 6 of those 9 countries are in the African Region. The number of pharmaceutical compa-nies marketing these products dropped from 38 in 2010 to 30 in 2013. Most of the countries that allow marketing of these medicines are in the African Region, whereas most of the manufacturers are in India.

34. Therapeutic e cacy studies remain the gold standard for guiding drug policy; such studies should be undertaken every 2 years. In 2011 and 2012, studies of rst- or second-line antimalarial treatments were completed in 48 of 67 (72%) countries where P. falciparum e cacy studies were possible an increase from 31 of 75 (41%) countries during 20082009. (In 32 countries with ongoing malaria transmis-sion, e cacy studies are currently impracticable because of low malaria incidence, or because the countries are endemic for P. vivax only.)

35. Parasite resistance to artemisinins has now been detected in four countries of the Greater Mekong subregion: Cambodia, Myanmar, Thailand and Viet Nam. Despite the observed changes in parasite sensitivity to artemisinins, ACTs continue to cure patients, provided that the partner drug is still e -cacious. In Cambodias Pailin province, resistance has been found to both of the components of multiple ACTs; there-fore, special provisions for directly observed therapy using a non-artemisinin-based combination (atovaquone + proguanil) have been introduced.

In April 2013, WHO released the Emergency response to arte-misinin resistance in the Greater Mekong subregion: Regional framework for action 20132015. The document describes priority areas in which action is needed in the coming years to contain artemisinin resistance.

Malaria surveillance, monitoring and evaluationIn 2012, in 62 countries of 103 that had ongoing malaria transmis-sion in 2000, reporting was considered to be su ciently consistent to make a reliable judgement about malaria trends for 20002012. In the 41 remaining countries, which account for 80% of estimated cases, it is not possible to reliably assess malaria trends using the data submitted to WHO. Information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest.

36. In 2012, routine health information systems detected only 14% of the cases estimated to occur globally. Case detec-tion rates were lowest in countries with the highest numbers of malaria cases. Similarly, the proportion of deaths that are

WORLD MALARIA REPORT 2013 | xiii

reported was lowest in countries with the greatest number of malaria deaths. Surveillance systems do not need to detect all cases in order to reliably assess trends; however, case detection e orts do need to be reasonably uniform over time. Countries with fewer estimated cases of malaria appear to be most able to assess trends in incidence. In the 41 countries that account for 80% of estimated cases in 2000, it is not possible to reliably assess malaria trends 20002012 using the data submitted to WHO. Thus, information systems are weakest where the malaria burden is greatest.

37. In contrast to routinely reported data, household surveys are more commonly undertaken in countries with the highest number of malaria cases. Fifty countries, of which 34 were in the African Region, had at least one household survey over the 3-year period 20112013. Indicators most commonly measured were those on the availability of ITNs and the use of antimalarial medicines. Only 25% of surveys included questions on fever cases receiving a nger stick or heel prick, whereas 90% enquired about malaria treatment a nding that will need to change if progress towards universal diag-nostic testing is to be tracked. The number of surveys that measure parasite prevalence has increased since 2005, rising to 81% of all surveys conducted between 2011 and 2013.

Impact of malaria control

Since 2000, more than half of the countries that had ongoing malaria transmission in 2000 have recorded decreases in the inci-dence of confi rmed malaria, or in reported admissions and deaths (or both). Estimated malaria mortality rates worldwide fell by 45% between 2000 and 2012 in all age groups, and by 51% in children under 5 years of age. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria mortality rates are projected to decrease by 56% in all ages, and by 63% in children under 5 years of age, by 2015.

38. An estimated 3.4 billion people were at risk of malaria in 2012. Of this total, 2.2 billion were at low risk (1 case per 1000 population) were living mostly in the African Region (47%) and the South-East Asia Region (37%).

39. Based on reported data, 59 out of 103 countries that had ongoing malaria transmission in 2000 are meeting the MDG target of reversing the incidence of malaria. Of these, 52 are on track to meet RBM and World Health Assembly targets of reducing malaria case incidence rates by 75% by 2015, including 8 countries of the African Region.

40. Decreases in the incidence of P. falciparum are, on average, larger than those of P. vivax, suggesting that P. vivax responds more slowly to control measures, possibly because of its biological characteristics. As a result, many NMCPs need to give greater attention to the control of P. vivax as they near elimination, particularly in areas outside sub-Saharan Africa. In countries where both species are transmitted, P. vivax predominates in countries that are in the pre-elimination and elimination phases.

41. Of 97 countries with ongoing transmission in 2013, 12 are classi ed as being in the pre-elimination phase of malaria control, and 7 as being in the elimination phase. A further 7 countries are classi ed as being in the prevention of intro-duction phase. In 2012, the European Region reported only 255 indigenous cases; hence, it is close to attaining the goal of eliminating malaria from the region by 2015, as set out in the 2005 Tashkent Declaration. Nonetheless, recent outbreaks in Greece and Turkey highlight the continual threat of reintroduction, and the need for continued vigi-lance to ensure that any resurgence is rapidly contained.

42. The 52 countries that are projected (based on reported data) to decrease malaria incidence by 75% by 2015 accounted for only 8 million (4%) of the total estimated cases of 226 million in 2000. This is partly because progress has been faster in countries with lower numbers of cases, but is also in u-enced by the poorer quality of surveillance data submitted by countries with larger numbers of cases. Improved surveil-lance and evaluation in countries with higher malaria burdens is essential for the impact of malaria investments to be properly assessed.

43. Because countries with higher numbers of cases are less likely to submit su ciently consistent data for assessing trends, it is necessary to draw inferences about trends in these countries using estimated numbers of cases rather than surveillance data. There were an estimated 207 million cases of malaria worldwide in 2012 (uncertainty interval, 135287 million). Most of the estimated cases (80%) occur in sub-Saharan Africa. About 9% of estimated cases glob-ally are due to P. vivax, although the proportion outside the African continent is 50%. The estimated incidence of malaria fell by 29% globally between 2000 and 2012, and by 31% in the African Region. If the annual rate of decrease that has occurred over the past 12 years is maintained, then malaria case incidence is projected to decrease by 36% globally by 2015, and by 40% in the African Region.

44. There were an estimated 627 000 malaria deaths worldwide in 2012 (uncertainty interval, 473 000789 000). Of the esti-mated deaths, most occur in sub-Saharan Africa (90%) and in children under 5 years of age (77%). Between 2000 and 2012, estimated malaria mortality rates decreased by 45% world-wide and by 49% in the African Region; they are estimated to have decreased by 51% in children under 5 years of age globally and by 54% in the African Region. If the annual rate of decrease that has occurred over the past 12 years is main-tained, then malaria mortality rates are projected to decrease by 56% globally and by 62% in the African Region by 2015. In children under 5 years of age, they are projected to decrease by 63% globally and by 68% in the African Region by 2015.

45. The pace of decrease in estimated malaria mortality rates accelerated from 2005, but slowed between 2011 and 2012. This slowing is partly because the model that is used to esti-mate malaria deaths in children under 5 years of age in Africa uses ITN coverage to adjust the proportion of all deaths that are attributed to malaria, and ITN coverage attened in 20112012 following decreases in funding for malaria control in 2011.

xiv | WORLD MALARIA REPORT 2013

46. More than 80% of estimated malaria deaths in 2012 occur in just 17 countries, and 80% of cases occur in 18 countries, with the Democratic Republic of the Congo and Nigeria together accounting for 40% of the estimated global total. Targets for reduction of cases and deaths will not be attained unless substantial progress can be made in countries that account for the vast majority of the malaria burden.

47. Four countries account for more than 80% of estimated cases of P. vivax cases (Ethiopia, India, Indonesia and Pakistan). P. vivax infection has been associated with severe malaria and death, although the risks of severe disease and case fatality rates for P. vivax infection have not been fi rmly established. The presence of comorbidities in particular, concomitant malnutrition is suspected to increase the risk of severe disease in P. vivax infection, although this risk also remains poorly defi ned. Further study is required to refi ne existing knowledge of the spectrum of severe P. vivax malaria, and the risks of severe disease and death with this infection.

48. Progress in reducing malaria case incidence and mortality rates has been faster in countries with lower numbers of cases and deaths in 2000. However, the vast majority of numbers of cases and deaths averted between 2000 and 2012 have been in countries that had the highest malaria burdens in 2000. If the malaria incidence and mortality rates in 2000 had remained unchanged over the decade, 500 million more cases and 3.3 million deaths would have occurred between 2001 and 2012. Most of the malaria cases averted (67%) and lives saved (93%) have been in the African Region.

49. Of the 3.3 million deaths averted between 2001 and 2012, 3 million (90%) are estimated to be in children under 5 years of age in sub-Saharan Africa. They account for 20% of the 15 million child deaths that are estimated to have been averted in sub-Saharan Africa since 2000 through overall reductions in child mortality rates. Thus, decreases in malaria deaths have contributed substantially to progress towards achieving the target for MDG 4 of reducing, by two thirds, the under-5 mortality rate between 1990 and 2015.

WORLD MALARIA REPORT 2013 | xv

Cette anne, le Rapport sur le paludisme dans le monde fait tat de lavance remarquable de la lutte mondiale contre le paludisme, et prsente les estimations du poids de la maladie

mises jour pour la priode 2000-2012. Le rapport rvle que les engagements politiques accrus et laugmentation des investisse-ments mondiaux en faveur de la lutte antipaludique depuis 2000 ont conduit des avances majeures en la matire, lorigine de 3,3 millions de vies sauves selon les estimations.

Chaque anne, nos connaissances sur les tendances du paludisme et sur le fardeau de la maladie dans le monde samliorent, compa-rativement la situation qui prvalait en 2000. Selon les estimations les plus rcentes, les taux de mortalit imputables au paludisme ont t rduits denviron 45 % dans le monde et de 49 % dans la Rgion africaine de lOMS entre 2000 et 2012. Au cours de la mme priode, les taux dincidence du paludisme ont diminu de 29 % au niveau mondial et de 31 % dans la Rgion Afrique. Ces rductions impor-tantes sont le rsultat dune intensi cation majeure des interventions de lutte antivectorielle, de lutilisation des tests diagnostiques et des traitements par une combinaison thrapeutique base dartmisi-nine ou CTA.

Mais cette avance ne permet pas de cder lautosatisfaction. Les chi res absolus des cas de paludisme et de dcs ne diminuent pas aussi rapidement quils le pourraient. La maladie a encore emport 627 000 vies en 2012 selon les estimations, principalement des enfants de moins de cinq ans en Afrique. Cela correspond 1 300 vies de jeunes enfants perdues chaque jour cause du paludisme, un rappel fort indiquant que la victoire sur cet ennemi de longue date nest pas pour demain. Le fait que tant de personnes meurent de piqres de moustiques est lune des plus grandes tragdies du XXIe sicle.

Si les engagements politiques sessou ent, les progrs majeurs qui ont t raliss pourraient tre anantis en une seule saison de trans-mission dans certaines zones. Au cours de ces dernires annes, nous avons commenc constater les premiers signes dun possible ralen-tissement. En 2011 et 2012, la livraison de moustiquaires imprgnes dinsecticide de longue dure aux pays dendmie palustre sest ralentie et les programmes de pulvrisations intradomiciliaires din-secticides e et rmanent ont stagn. Pendant cette mme priode, les taux de mortalit dus au paludisme ont continu diminuer, mais un rythme plus lent. En 2013, les livraisons de moustiquaires ont nouveau augment, et celles prvues lanne prochaine sont encore suprieures. Toutefois, des e orts encore plus importants devront tre consentis pour protger toutes les personnes risque.

Alors que la communaut internationale avance progressivement vers le programme de dveloppement pour laprs-2015, nous ne devons par perdre de vue ce que les populations les plus vulnrables attendent de nous. Le concept de couverture sanitaire universelle reprsente la fois une valeur sociale et une approche des soins qui gnre une meilleure sant pour des populations entires, rduit les ingalits sociales et protge de la pauvret induite par les dpenses de soins de sant. Il sagit dun concept cl qui occupe dj le centre

du dbat mondial sur la sant, mais aussi le centre du dbat sur le prochain ensemble dobjectifs pour le dveloppement. Les progrs raliss dans la lutte contre le paludisme sont une preuve satisfaisante des bn ces tangibles de laccs des interventions vitales pour lensemble des populations.

La communaut internationale doit aussi continuer se mobiliser pour combler lcart dans les nancements internationaux consacrs la prvention et la lutte antipaludiques. Les nancements actuel-lement disponibles sont largement insu sants pour tablir laccs universel aux interventions de lutte antipaludique. Pour atteindre notre objectif, nous devons intensi er les e orts visant amliorer les outils de lutte antivectorielle. Nous devons aussi garantir que les groupes les plus vulnrables, cest--dire les enfants de moins de cinq ans, les nourrissons et les femmes enceintes, ont accs aux trai-tements prventifs intermittents recommands par lOMS, lorsquils sont adapts. Si les progrs en matire dlargissement de lutilisation des tests diagnostiques et de traitements satisfaisants aux normes dassurance qualit ont t considrables au cours de ces dernires annes, nous sommes toutefois loin datteindre laccs universel.

En outre, la rsistance parasitaire lartmisinine le composant principal des mdicaments antipaludiques les plus e caces au monde et la rsistance des moustiques aux insecticides restent des proccupations majeures. Si elles ne sont pas prises en compte avec la diligence requise, ces dernires pourraient menacer les progrs remarquables accomplis depuis 2000. Si lOMS a publi des strat-gies mondiales pour surmonter ces di cults, leur adoption par les pays est lente, principalement en raison de linsu sance des nance-ments. En avril 2013, lors de la Journe mondiale du paludisme, lOMS a publi louvrage Emergency response to artemisinin resistance in the Greater Mekong subregion (Riposte duregence la rsistance lartmisi-nine dans la sous-rgion du Grand Mkong) pour orienter les pays dans lintensi cation et la mise en uvre des interventions visant llimina-tion des parasites rsistants. Lcart de nancement pour cette inter-vention est aussi trs important.

Le renforcement des infrastructures de sant, les systmes de surveil-lance et de noti cations vitales sont galement indispensables pour obtenir de nouveaux progrs. Selon les donnes soumises, 59 pays ont atteint la cible de lOMD dinverser la tendance de lincidence du paludisme, et 52 pays sont en bonne voie vers une rduction de leur taux dincidence des cas de paludisme de 75 %, dans le droit l des cibles xes pour 2015 par lAssemble mondiale de la sant et le partenariat Roll Back Malaria. Toutefois, ces 52 pays reprsentent seulement 4 % ou huit millions des cas totaux estims de paludisme dans le monde. Dans 41 pays dendmie palustre, et notamment dans les pays o le fardeau du paludisme est le plus lourd, nous ne pouvons valuer de manire able les tendances du paludisme. Un e ort concert visant amliorer les systmes de surveillance est requis pour combler cet cart entre nos connaissances et la situation du paludisme.

LOrganisation est reconnaissante pour lengagement des ministres de la Sant des pays endmiques et de leurs nombreux partenaires du dveloppement. Nous sommes convaincus que si nous restons dtermins et agissons avec diligence, nous pouvons vaincre ce vieil ennemi une fois pour toutes.

Avant-proposDr Margaret ChanDirecteur Gnral de lOrganisation mondiale de la Sant (OMS)

xvi | WORLD MALARIA REPORT 2013

Rsum et points essentielsLe Rapport 2013 sur le paludisme dans le monde rcapitule les infor-mations communiques par des pays dendmie palustre ainsi que des renseignements manant dautres sources. Il sattache mettre jour les analyses gurant dans le Rapport 2012. Il souligne les progrs accomplis dans le but de contribuer au respect des objectifs internationaux xs lhorizon 2015 et dcrit les d s actuels en ce qui concerne la lutte et llimination du paludisme dans le monde.

Les annes coules depuis 2000 ont t marques par une augmentation considrable du nancement et de la couverture des programmes de lutte contre le paludisme. Cette situation a conduit une rduction grande chelle de lincidence du palu-disme et de la mortalit. Si lon se fonde sur les donnes soumises, 59 pays sur 103 o la transmission du paludisme tait active en 2000 atteignent lObjectif du Millnaire pour le dveloppement (OMD) dinverser la tendance du paludisme. Parmi ceux-ci, 52 sont en bonne voie pour atteindre les cibles xes par lAssemble mondiale de la sant et par le partenariat Roll Back Malaria (RBM Faire reculer le paludisme ) : rduire de 75 % le nombre de cas de paludisme dici 2015, et notamment dans huit pays de la rgion Afrique. Dans 41 pays, il nest pas possible dvaluer les tendances partir des donnes soumises en raison des incohrences dans lexhaustivit des donnes dans le temps, des modi cations dans les pratiques diagnostiques ou le recours aux services de sant. Pour ces pays, qui reprsentaient 80 % des cas en 2000, il est ncessaire dextrapoler les tendances partir des estimations des taux dincidence des cas et de mortalit imputables au paludisme.

Dans le monde, entre 2000 et 2012, les taux de mortalit estims dus au paludisme ont chut de 45 % dans toutes les tranches dge et de 51 % chez les enfants de moins de cinq ans. Si le taux annuel de diminution observ au cours des 12 dernires annes se con rme, alors les taux de mortalit imputables au paludisme pourraient diminuer de 56 % dans toutes les tranches dge, et de 63 % chez les enfants de moins de cinq ans, dici 2015. Ainsi, cela reprsente une avance importante vers la cible de lAssemble mondiale de la sant visant rduire les taux de mortalit du palu-disme de 75 % dici 2015.

La modlisation suggre que 3,3 millions de dcs imputables au paludisme ont t vits entre 2001 et 2012, et que 69 % de ces vies sauves se situaient dans les dix pays o la charge du paludisme tait la plus leve en 2000. Des progrs sont donc accomplis l o ils comptent le plus. Il a t estim quenviron 3 millions (90 %) des dcs vits entre 2001 et 2012 concernaient des enfants de moins de cinq ans en Afrique subsaharienne. Cela reprsente 20 % des 15 millions de dcs denfants qui ont t vits en Afrique subsaha-rienne depuis 2000 selon les estimations, en raison des rductions globales des taux de mortalit infantile. Par consquent, les dimi-nutions du nombre de dcs dus au paludisme ont considrable-ment contribu progresser vers la ralisation de lOMD 4, qui est de rduire de deux tiers, entre 1990 et 2015, le taux de mortalit des enfants de moins de cinq ans.

Cependant, entre 2011 et 2012, le rythme de diminution des taux de mortalit estims imputables au paludisme a ralenti. Ce ralentissement sexplique en partie parce que la modlisation qui

est applique pour estimer le taux de dcs chez les enfants de moins de cinq ans en Afrique utilise les donnes de la couver-ture des moustiquaires imprgnes dinsecticides longue dure (MII), alors que cette couverture a stagn entre 2011 et 2012 suite aux baisses du nancement de la lutte contre le paludisme en 2011. En 2012, le nancement des programmes de lutte contre le paludisme a t estim moins de la moiti des US$ 5,1 milliards estims ncessaires au niveau mondial. Des millions de personnes risque de paludisme nont toujours pas accs aux interventions telles que les MII, les pulvrisations intradomiciliaires dinsecti-cides e et rmanent (PII), les tests de diagnostic et les combinai-sons thrapeutiques base dartmisinine (CTA). En consquence, il a t estim quen 2012, environ 207 millions de cas (intervalle dincertitude : 135-287 millions) et 627 000 dcs (intervalle din-certitude : 473 000-789 000) taient imputables au paludisme. Il est urgent daugmenter le nancement de la lutte contre le palu-disme et dlargir la couverture des interventions, pour atteindre les cibles de rduction des cas et de dcs xes lchelle inter-nationale.

laboration de politiquesDes nouvelles politiques, des politiques actualises, des manuels oprationnels, des plans et des initiatives sur la lutte contre le palu-disme ont t publis en 2013, suite aux runions du Comit de pilo-tage de la politique de lutte antipaludique (MPAC).

1. Le MPAC, qui est devenu oprationnel en 2012, a poursuivi sa mission en 2013 consistant fournir des conseils stratgiques et une contribution technique lOrganisation mondiale de la Sant (OMS) sur tous les aspects de la lutte contre le palu-disme et son limination. Conformment aux recommanda-tions du MPAC, lOMS a publi des recommandations sur une vaste gamme de domaines politiques, notamment latteinte de la couverture universelle des MII, lestimation de leur long-vit, et le renforcement des capacits en matire dentomo-logie du paludisme et de la lutte antivectorielle.

2. Parmi les autres recommandations publies par lOMS en 2013, on peut citer (i) un manuel pratique pour les PII ; (ii) un manuel pratique pour la gestion des gtes larvaires ; (iii) des protocoles de test pour le suivi de la rsistance aux insecticides chez les moustiques vecteurs du paludisme ; (iv) un guide pratique sur la chimioprvention du paludisme saisonnier (CPS) ; (v) un guide pratique sur la prise en charge du paludisme grave ; (vi) un cadre dintervention pour la riposte la rsistance lartmi-sinine dans la sous-rgion du Grand Mkong ; (vii) un manuel pratique sur la lutte antipaludique dans les situations durgence complexes (labor avec le concours de plusieurs partenaires institutionnels) ; et (viii) trois manuels de formation.

Financement de la lutte antipaludiqueIl est prvu que les fonds a ects la lutte antipaludique en prove-nance de lensemble des sources de nancements internationaux et nationaux atteignent US$ 2,5 milliards en 2012, cest--dire un

WORLD MALARIA REPORT 2013 | xvii

montant sensiblement infrieur aux ressources ncessaires pour atteindre les cibles fi xes au niveau mondial.

3. Les nancements internationaux allous aux pays dendmie palustre ont nettement augment, passant dun peu moins de US$ 100 millions en 2000 US$ 1,6 milliard en 2011 et ont t estims US$ 1,94 milliard en 2012 et 1,97 milliards en 2013. Toutefois, laugmentation des nancements internationaux a ralenti au cours des dernires annes, passant une moyenne de 4 % par an entre 2009 et 2013, par rapport une moyenne annuelle de 43 % entre 2005 et 2009.

4. Les donnes soumises suggrent que le nancement national de la lutte contre le paludisme a augment au cours de la priode 2005-2012, passant de US$ 436 millions en 2005 US$ 522 millions en 2012. Laugmentation des dpenses nationales consacres au paludisme a t estime un taux annuel de 4 % entre 2005 et 2012.

5. Dans le Plan daction mondial contre le paludisme (GMAP) du partenariat RBM en 2008, les besoins en ressources lchelle mondiale ont t estims plus de US$ 5,1 milliards par an entre 2011 et 2020. En combinant les fonds nationaux et inter-nationaux, les ressources disponibles pour la lutte antipaludique dans le monde ont t estimes US$ 2,5 milliards en 2012, laissant un cart de US$ 2,6 milliards. Les prvisions pour les ressources nationales et internationales disponibles entre 2013 et 2016 indiquent que le nancement total de la lutte contre le paludisme atteindra environ US$ 2,85 milliards entre 2014 et 2016, un montant sensiblement infrieur aux besoins pour concrtiser laccs universel aux interventions antipaludiques.

6. Les nancements internationaux de la lutte antipaludique ont vis les pays o le revenu national brut par habitant tait le plus faible et o les taux de mortalit taient les plus levs, notamment les pays dAfrique. Toutefois, les nancements nationaux sont plus levs dans les pays les plus riches et plus faibles dans les pays o les taux de mortalit imputables au paludisme sont plus levs. Les faibles niveaux de dpenses intrieures des pays o le fardeau de la maladie est le plus lourd sexpliquent principalement par un revenu intrieur par habitant plus faible dans ces pays.

7. Il existe des disparits entre les degrs de priorit accords la lutte contre le paludisme par les gouvernements nationaux ayant des niveaux de ressources disponibles similaires. Les pays qui font preuve dun engagement plus important, mesur par un indice de priorit des investissements nationaux, ont eu davantage de succs dans la rduction de lincidence des cas de paludisme entre 2000 et 2012 que les autres pays.

Progrs raliss dans la lutte antivectorielleEn Afrique subsaharienne, le pourcentage de la population ayant accs une MII au sein de leur foyer a fortement augment entre 2005 et 2011, mais a plafonn ces deux dernires annes pour repasser 42 % en 2013. Des distributions plus importantes de MII au cours des deux prochaines annes pourraient accrotre la couverture.

Moustiquaires imprgnes dinsecticide

8. Ds 2012, 34 pays de la Rgion Afrique et 82 pays situs dans dautres rgions du monde avaient adopt les recommanda-

tions de lOMS prconisant la fourniture de MII toutes les personnes exposes au paludisme. Au total, 88 pays, dont 39 en Afrique, distribuent gratuitement des MII.

9. Chaque anne, selon les estimations, au moins 150 millions de MII sont ncessaires pour maintenir un approvisionne-ment de 450 millions de MII dans les foyers pour une priode de trois ans et protger toutes les populations risque de paludisme en Afrique subsaharienne. Le nombre annuel de MII livres par les fabricants aux pays dendmie palustre en Afrique subsaharienne a augment pour passer de 6 millions en 2004 145 millions en 2010. Toutefois, en 2011, seule-ment 92 millions de MII ont t livrs par les fabricants et leur nombre tait de seulement 70 millions en 2012. Le nombre estim de MII livres en 2013 (136 millions) et le nombre de MII couvertes par des dons en 2014 (environ 200 millions) sont proches du nombre de MII ncessaire tous les ans pour protger toutes les populations risque. Pourtant, malgr laugmentation des livraisons annuelles, le nombre total de MII sur trois ans (400 millions), cumulant les MII livres en 2012, celles dont la livraison est estime pour la n de 2013 et celles pour lesquelles le nancement a t runi pour 2014, reste infrieur au nombre minimum requis pour protger toutes les personnes exposes au paludisme. Les niveaux adapts de livraison de MII requis doivent tre assurs chaque anne, pour garantir la disponibilit des MII dans les foyers et laccs une MII toute personne risque de paludisme.

10. Le pourcentage de mnages possdant au moins une MII en Afrique subsaharienne a augment selon les estimations, passant de 3 % en 2000 56 % en 2012, puis a lgrement diminu pour passer 54 % en 2013. Le pourcentage de la population ayant accs une MII au sein de son foyer a augment pendant la mme priode, pour atteindre 44 % en 2012 et 42 % en 2013. La proportion de la population dormant sous une MII, reprsentant la population directe-ment protge, a t estime 38 % en 2012 et 36 % en 2013.

11. La comparaison du pourcentage de la population ayant un accs une MII et du pourcentage dormant sous cette mous-tiquaire laisse penser quune forte proportion (86 %) de la population ayant accs cette protection lutilise rellement, indiquant que les e orts visant encourager son utilisation ont t e caces. Le principal obstacle empchant un plus grand nombre de personnes exposes au paludisme de dormir sous une MII se rsume la disponibilit insu sante des moustiquaires.

12. Lutilisation de MII au sein des populations vulnrables, comme les femmes enceintes et les enfants de moins de cinq ans, est suprieure la frquence de son utilisation en popu-lation gnrale. Cela indique que ces groupes restent mieux protgs tandis que les pays intensi ent leurs e orts vers une couverture universelle des MII, et souligne le besoin daug-menter laccs cette moustiquaire pour toutes les personnes risque.

Pulvrisations intradomiciliaires dinsecticides e et rmanent (PII)

13. Les PII laide dinsecticides e et rmanent constituent encore un outil de lutte antivectorielle puissant destin rduire ou interrompre la transmission du paludisme. En 2012,

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88 pays, dont 40 pays dans la Rgion Afrique, recomman-daient les PII dans la lutte contre le paludisme.

14. En 2012, 135 millions de personnes (4 % de la population mondiale expose) taient protgs par des PII dans le monde. Dans la Rgion Afrique, la proportion de la population expose qui a t protge a augment, passant de moins de 5 % en 2005 11 % en 2010, puis est tombe 8 % en 2012, avec 58 millions de bnfi ciaires. La diminution du nombre de personnes protges par des PII en Afrique semble en partie due une augmentation du recours des insecticides non-pyrthrinodes plus coteux, en raction la menace de la rsistance aux insecticides dans un contexte de budgets allous aux PII limits. Lutilisation dinsecticides non pyrth-rinodes pour les PII peut devenir de plus en plus importante en tant quoutil de gestion de la rsistance, car actuellement toutes les MII approuves sont base de pyrhrinode.

Rsistance aux insecticides

15. Une rsistance des moustiques au moins un insecticide utilis dans la lutte contre le paludisme a t constate dans au moins 64 pays dendmie palustre dans le monde. En mai 2012, lOMS et le partenariat RBM ont publi le Plan mondial pour la gestion de la rsistance aux insecticides chez les vecteurs du paludisme (GPIRM). Le GPIRM est une stratgie cinq piliers de gestion de la menace de rsistance aux insec-ticides. Les parties prenantes de la communaut mondiale de lutte contre le paludisme ont entam des interventions lies la mise en uvre de la stratgie labore dans le Plan mondial pour la gestion de la rsistance aux insecticides.

16. Le suivi de la rsistance aux insecticides est une composante indispensable au dploiement des interventions de lutte antivectorielle fondes sur des insecticides. En 2012, 58 pays ont signal avoir adopt une politique de suivi systmatique de la rsistance aux insecticides.

Progrs raliss en matire de chimioprventionParmi les pays africains soumettant ces donnes lOMS en 2012, le pourcentage mdian de femmes enceintes se prsentant dans des tablissements de soins prnatals et ayant reu au moins une dose du traitement prventif intermittent (TPI) durant leur grossesse tait de 64 % tandis que 38 % avaient reu au moins deux doses et 23 % au moins trois doses, pointant vers une marge damlioration consid-rable dans le domaine de la protection des femmes enceintes.

17. En Afrique subsaharienne, il a t estim que 35 millions de femmes enceintes et une grande partie des 26 millions de nourrissons ns chaque anne tireraient avantage dune TPI. En outre, environ 25 millions denfants dans la rgion sah-lienne de lAfrique subsaharienne pourraient tre protgs contre le paludisme au moyen dune chimioprvention saisonnire du paludisme (CSP).

18. Au total, en Afrique subsaharienne, 36 pays o lintensit de la transmission du paludisme est comprise entre modre et leve ont adopt ds la fi n 2012 le TPI pour femmes enceintes (TPIp) comme politique nationale. Dans la Rgion Pacifi que occidental, la Papouasie-Nouvelle-Guine a gale-ment adopt cette politique en 2009.

19. Dans 26 pays sur les 36 pays de la Rgion Afrique o la trans-mission du paludisme est de modre lev, qui ont adopt le TPIp en tant que politique nationale et pour lesquels des donnes sont disponibles, 64 % (mdiane) des femmes enceintes se prsentant dans des tablissements de soins prnatals ont reu en 2012 au moins une dose du traitement prventif intermittent durant leur grossesse, 38 % ont reu au moins deux doses et 23 % au moins trois doses. Dans les 13 pays de la Rgion Afrique disposant de donnes provenant denqutes auprs des mnages sur la priode 2010-2012, la moyenne pondre de toutes les femmes ayant reu une dose de TPIp pendant leur grossesse tait de 37 % ; 23 % avaient reu deux doses et 8 % trois doses.

20. Depuis octobre 2012, lOMS recommande dadministrer une dose de TPIp chaque visite prnatale programme aprs le premier trimestre de grossesse. Lanalyse des donnes issues denqutes auprs des mnages indique que la proportion de femmes enceintes qui reoit le TPIp est trs infrieure celle des femmes se prsentant dans des tablissements prnatals. Le pourcentage estim de visites dans ces tablissements au cours desquelles le TPIp pourrait tre administr mais nest pas administr est lev, se montant 72 %. La proportion de femmes bnfi ciant du TPIp au cours de leurs visites prnatales est infrieure au pourcentage de femmes recevant lanatoxine ttanique (une autre composante cl des soins prnatals). Cet cart indique que la capacit fournir des services prven-tifs pendant les visites prnatales est trs leve, et que les obstacles au TPIp peuvent tre franchis.

21. Tous les nourrissons exposs un risque dinfection par P. falci-parum dans des pays dAfrique subsaharienne o lintensit de la transmission est comprise entre modre et leve et o les niveaux de rsistance des parasites aux agents recommands (la sulfadoxine-pyrimthamine) sont faibles, devraient recevoir un traitement prventif contre le paludisme par les services de vaccination, selon des intervalles dfi nis correspondant aux calendriers de vaccination systmatique. Seul un pays, le Burkina Faso, a fait du TPI un lment de sa politique nationale dans le cas des nourrissons depuis sa recommandation par lOMS en 2009.

22. En mars 2012, lOMS a publi des recommandations sur la chimioprvention saisonnire du paludisme (CSP) chez les enfants gs de 3 59 mois, et en aot 2013, lOMS a publi un manuel pratique pour une mise en uvre de la CSP. Deux pays dendmie ont adopt la CSP et plusieurs pays impliqus dans lvaluation de la politique ont indiqu quils prvoyaient dadopter cette politique et dlargir la couverture de la CSP dautres populations que celle de ltude.

Progrs raliss en matire de test de diagnostic et de traitement antipaludiqueLes achats de tests de diagnostic rapide (TDR) et de combinaisons thrapeutiques base dartmisinine (CTA) sont en augmentation tout comme le taux notifi des tests de diagnostic dans le secteur public de la Rgion Afrique qui est pass de 37 % en 2010 61 % en 2012. En consquence, une rduction du nombre de cas suspects de paludisme traits prsomptivement par des antipaludiques a t observe. Toutefois, des millions de personnes chez qui un paludisme

WORLD MALARIA REPORT 2013 | xix

est suspect ne reoivent toujours pas de test de diagnostic, et de nombreuses personnes dont linfection est confi rme ne bnfi cient pas dun traitement antipaludique appropri satisfaisant aux normes dassurance qualit.

Tests de diagnostic

23. La mise en uvre universelle des tests de diagnostic dans les secteurs publics et privs rduirait considrablement les besoins en traitements antipaludiques dans le monde. En 2012, 41 des 44 pays de la Rgion Afrique a chant encore des taux de transmission du paludisme et 48 sur 55 pays des autres Rgions de lOMS ont signal avoir adopt une poli-tique visant fournir le diagnostic parasitologique toutes les tranches dge, ce qui reprsente six pays de plus quen 2009 pour la Rgion Afrique.

24. Le test de diagnostic du paludisme est o ert gratuitement dans le secteur public de 84 pays dans le monde. La propor-tion des cas suspects de paludisme soumis un test de diagnostic dans le secteur public a augment, passant de 37 % en 2010 61 % en 2012 dans la Rgion Afrique et de 44 % 64 % dans le monde. Lessentiel de cette augmentation dans la Rgion Afrique est imputable une utilisation accrue des TDR, qui reprsente 40 % de tous les cas dpists dans la Rgion en 2012.

25. Le nombre de patients soumis un examen microscopique a augment, pour culminer 188 millions en 2012, tandis que lInde reprsente plus de 120 millions dexamens de prlve-ments sanguins sur lames. Le nombre de TDR fournis par les fabricants est pass de 88 millions en 2010 205 millions en 2012. Ce chi re comprend les ventes accrues pour les tests spci ques de P. falciparum et les tests combins qui peuvent dtecter plus dune espce de parasites.

26. Au total, 48 pays ont dclar avoir dploy des TDR au niveau communautaire et 15 millions de patients ont t soumis un test de diagnostic grce ces programmes en 2012, selon les noti cations. Daprs lanalyse des donnes issues des enqutes auprs des mnages de 14 pays menes entre 2010 et 2012, il semblerait que les tests de diagnostic soient moins rpandus dans le secteur priv que dans le secteur public.

27. Les TDR sont de plus en plus utiliss pour le dpistage des cas suspects de paludisme dans les tablissements de sant, notamment pour le diagnostic de P. vivax. Sur les 42 pays prcisant le type de TDR utilis, 15 ont dclar avoir dploy des TDR capables de dpister spci quement P. vivax. Dans ces pays, le pourcentage de cas infects par P. vivax con rms par TDR (plutt que par microscopie) tait similaire au pour-centage de cas infects par P. falciparum con rms par TDR.

Traitement28. Une CTA est recommande dans le traitement de premire

intention du paludisme P. falciparum, le parasite Plasmodium le plus dangereux qui infecte les humains. En 2012, 79 pays et territoires ont adopt la CTA en traitement de premire inten-tion pour le paludisme P. falciparum. Le paludisme P. vivax doit tre trait par la chloroquine partout o cet antipalu-dique reste e cace ou par une CTA dans les zones o P. vivax est rsistant la chloroquine. Le traitement du paludisme P.

vivax doit tre complt par ladministration de primaquine pendant 14 jours a n dviter les rechutes.

29. Selon les rapports de fabricants et le Dispositif pour des mdi-caments abordables pour le paludisme (DMAp), le nombre de traitements par CTA livrs aux secteurs publics et privs dans le monde a augment, passant de 11 millions en 2005 76 millions en 2006, pour atteindre 331 millions en 2012. Cette hausse des achats de CTA en 2012 sexplique en grande partie par une augmentation denviron 50 % des livraisons dans le secteur public entre 2011 et 2012. Lachat de mdicaments pour le secteur public et le secteur priv par le DMAp qui est actuellement dans une phase de transition vers une ven-tuelle intgration dans un processus doctroi de subventions systmatique pour le Fonds mondial de lutte contre le sida, la tuberculose et le paludisme (le Fonds mondial), sest lgre-ment ralenti, passant de 156 millions de traitements en 2011 150 millions en 2012.

30. Il est di cile de savoir dans quelle mesure les patients dont le paludisme a t con rm ont reu des traitements antipa-ludiques car les informations reliant le test de diagnostic au traitement ont t limites dans les deux enqutes auprs des mnages et les systmes dinformation sanitaire courants. Il est possible destimer la proportion de patients dans le secteur public potentiellement traite par CTA (plutt que par un antipaludique moins e cace) en comparant le nombre de traitements par CTA distribus par les programmes nationaux au nombre de cas de paludisme prsums (traits sans test pralable) et de cas de paludisme P. falciparum con rms (par examen microscopique ou TDR) (corrigs pour lexhausti-vit des donnes soumises, ou estims dans les situations o les donnes nont pas t soumises). Cette proportion varie en fonction des Rgions de lOMS, mais a augment au l du temps dans la Rgion Afrique, o elle a atteint 60 % en 2012.

31. Dans neuf pays de la Rgion Afrique o plus dune enqute auprs des mnages a t mene entre 2006 et 2012, la proportion denfants fbriles sous antipaludiques ayant reu une CTA a augment au l du temps, dans le secteur public comme le secteur priv. Dans les enqutes les plus rcentes, le pourcentage mdian denfants sous antipaludiques ayant reu une CTA tait de 68 % ; toutefois, une part importante denfants ntant pas prsente aux services de soins pour un motif de vre, et tous les enfants chez qui un paludisme est suspect ne recevant pas un test diagnostique, le pourcen-tage de tous les enfants atteints de paludisme recevant une CTA est probablement trs infrieur. Dans 26 enqutes auprs des mnages menes entre 2010 et 2012 se fondant sur un rsultat positif au TDR chez les enfants fbriles comme indi-cateur indirect pour con rmer le diagnostic de paludisme, le pourcentage moyen de tous les enfants dont linfection a t con rme et qui ont reu une CTA tait de 16 % (extrmes : 1 %-42 %). Un accs accru aux soins en cas de vre, ainsi que des tests de diagnostic et une prise en charge thrapeutique adapte dans tous les lieux de soins, sont indispensables pour garantir que tous les patients sou rant de paludisme reoivent un traitement rapide et e cace.

32. Dans la Rgion