Prevention, Treatment and Malaria Control: A Southern America Perspective

Abstract

Malaria is one of the diseases with the highest morbi-mortality rate worldwide, including Colombia, where it is endemic in several regions of the country. Although the incidence of this disease in the Department of Meta and the Atlantic Coast is not as high as in Nariño, the number of reported cases has held steady over time. It is still an event of great interest in public health. The struggle against malaria is part of one of the Millennium Development Goals and has generated global and national programs that have been implemented at a national and global level, whose main goal is to control and eradicate malaria. These programs have stood out for their vertical nature and for the low level of community participation. Health sector needs to include, at a micro-level, the voices of the community represented in their discourses and actions in the face of the disease, its prevention, and treatment. Therefore, a community and institutional look at these elements, in relation to the disease and the vector, should be provided, which will allow the vector and disease control programs to be improved, designing strategies to bring community and government agencies together to propose public health policies and programs.

1. Introduction

Malaria remains a global public health problem, with nearly 3.2 billion people in 97 countries at risk of being infected and developing the disease, leading to a high social and economic burden. According to the World Health Organization, malaria cases have increased since 2015, showing a significant increase not only in morbidity but also in mortality in 2020, due in part to the COVID-19 pandemic [1]. Significant progress has been made in malaria control over the past two decades in America, but in recent years, there has been stagnation and an increase in the number of cases in countries such as Venezuela (811.5% between 2010 and 2017) and Nicaragua (1482.2% between 2010 and 2017) [2]. During 2021, 72,022 cases of malaria occurred in Colombia; 70,838 of them were non-complicated malaria, and 1184 were complicated malaria (1.64%). The annual parasite index was 8.93 cases per 1000 inhabitants, with a predominance of Plasmodium falciparum (49.6%) and P. vivax (49.4%). Mixed infections accounted for only 0.9%. During that year, major outbreaks occurred in 13 municipalities of the country, and the most affected departments where Choco, Nariño, Cordoba, Amazonas, Antioquia, Meta, and Caqueta. 57.8% of the cases occurred in men, and 738 cases were reported in pregnant women [3].

Malaria is a multicausal disease, and therefore, new approaches to control it are comprehensive and include individual, community, and institutional participation to strengthen the capacity of local response to achieve a sustainability of actions with an emphasis on promoting good health and preventing malaria [4]. However, despite existing policies, plans, and programs, malaria remains a serious public health problem in the country. Since the dawn of the twentieth century and during the time of public hygiene, malaria and anemia produced by uncinaria have been considered one of the priorities for control [5]. Between 1956 and 1993, a vertical control program was carried out in Colombia headed by the Ministry of Health’s Direct Campaigns Directorate and the Malaria Eradication Service (SEM by its Spanish acronym), a program that ran parallel to the National Health System [6]. During the nineties, profound reforms to the health system were carried out through Law 100 of 1993, which led to the dismantling of the programs headed by the state, transforming the fight against malaria into a control program with several actors involved [7].

Nevertheless, malaria is a disease that is closely related to the level of poverty in a community. It slows economic growth and perpetuates the vicious cycle of poverty. Rural areas are the most vulnerable since buildings and living facilities are deficient and generally have little or no protection against mosquitoes [8].

In Colombia, rural areas reveal concerning levels of health indicators; high levels of malnutrition; low levels of schooling of the population; higher illiteracy rates; and low coverage of basic public utilities, including potable water, sewerage, and electricity. This problem is largely due to the geography, the great distances and topographic difficulties of the terrain that make it difficult to enter certain areas, and also public order issues due to the presence of armed conflict participants and very low or lack of presence of health service providers [9]. These socio-economic factors play an important role in malaria transmission and in other human activities that foster movement of populations, such as migration and wars, leading to the spread of both the parasite and the vector [10].

According to the programs derived from the health system reform, malaria control activities are divided into collective actions (headed by the state) and individual actions (headed by health insurers and health services providers). The following activities are carried out as part of the collective activities included in Collective Interventions Plan (PIC by its Spanish acronym) headed by local authorities, vector control, intra- and peri-domiciliary fumigation, handing out bed nets (mosquito nets), and the supervision of the event by the municipality [11] (National Health Institute, 2014). However, programs are designed without the participation of the communities involved, ignoring local knowledge and socio-political and cultural dynamics surrounding their main health problems, in this case malaria. This leads to imposing out-of-context control measures that reduce the coverage and impact of interventions [12].

Communities forge discourses and knowledge about health and illness that are reflected in attitudes and individual actions that can contribute to the success or failure of the program. Community participation in health programs requires measurable changes in behaviors that allow for active personal involvement in decision-making regarding the health of their own families. Health personnel also have their own views of community affairs from their knowledge, hierarchies, and practices. These discourse and activities draw paths of malaria prevention, treatment, and control, often parallel to and with no contact between them. This is the reason why the community perspective needs to be incorporated into institutional programs.

In light of the aforementioned, the health sector needs to include, at a micro-level, the voices of the community represented in their discourses and actions in the face of the disease, its prevention, and treatment. It is important to note that the studies carried out so far in Colombia have focused on areas with high endemic rates. Nonetheless, it is important to keep an eye on community and governmental dynamics in areas where the number of cases is not high but has remained constant throughout the years and where outbreaks eventually occur.

2. Epidemiological depiction of malaria in the world and in Colombia

Malaria, a disease transmitted by mosquitoes of the genus Anopheles and produced by parasites of the genus Plasmodium, remains a global public health problem, with nearly 3.2 billion people in 97 countries at risk of being infected and developing the disease, leading to a high social and economic burden [13]. Between 2000 and 2020, an estimated 1.7 billion cases and 10.6 million deaths worldwide were estimated, falling from 896,000 in 2000 to 558,000 in 2015. However, there was an increase (627,000) partly due to the COVID-19 pandemic [1].

By 2020, there were 18 endemic countries in the Americas, accounting for 0.3% of the total malaria cases in the world. Brazil, Colombia, and Venezuela accounted for 77% of the cases in the region. In the past 20 years, significant advances have been made in decreasing the incidence in endemic countries, from 14.1 to 4.6 cases per 1000 inhabitants at risk and a 58% reduction in overall cases. Mortality also decreased from 0.8 to 0.3 deaths per 100,000 inhabitants at risk. Despite this, countries such as Venezuela have significantly increased the number of infections, from 35,500 in the year 2000 to more than 467,000 in 2019, affecting the statistics in the region. Other countries such as Bolivia, Haiti, Honduras, Nicaragua, and Panama showed substantial increases in 2020 in comparison to 2019 [1].

In Colombia, malaria is present in more than 80% of the national territory, with five macro-foci of variable and active transmission: the Pacific Region (departments of Choco, Nariño, and Cauca and the district of Buenaventura in Valle del Cauca), the Amazone-Orinoquia Region (departments of Amazonas, Vichada, Guainia, and Guaviare), Magdalena Medio (Antioquia, Bolivar, and Cordoba), and a recent focus on the border with Venezuela (department of Norte de Santander) [14]. Thanks to its extensive and diverse social and environmental conditions that have led to the transmission and endemicity of this disease in the country [15], malaria still represents a serious public health issue.

During the year 2015, 56,705 malaria cases were reported in the system in Colombia. 55,866 were cases of non-complicated malaria, and 839 were cases of complicated malaria. 18 deaths from this disease were reported. Choco, Nariño, and Antioquia headed the list of reports, accumulating more than 75% of total cases in the country [16]. By 2016, the increase in cases was evident, with 84,742 reports, of which 83,227 were non-complicated malaria and 1515 were complicated malaria. Additionally, 26 confirmed deaths and 10 deaths classified as compatible cases were reported [17]. During 2017, the decline in cases was evident, with a total of 55,117 reports across the country. The departments of Choco, Nariño, Antioquia, Cordoba, Guainia, Amazonas, Cauca, and Vichada registered 90.7% of cases of non-complicated malaria [18]. For the year 2018, there was a 14.6% increase compared to the previous year, with a total of 63,143 reported cases of malaria in the country. 54% of the cases came from the Pacific region, with the department of Choco (27.7%) being the largest reporter of cases, followed by the department of Nariño, with 21.8% [19]. For the year 2019, there was a situation of sustained malaria outbreak throughout the year, with a total of 80,415 cases reported in the system, of which 79,120 (98.3%) were classified as non-complicated malaria and 1295 (1.6%) were classified as complicated malaria [20]. Similar numbers were observed during 2020, with a total of 80,236 malaria reports in the public health monitoring system. Despite the health emergency caused by COVID-19 and the mandatory preventive isolation that occurred in the country from epidemiological week 12 to week 32, the country was hit by a malaria outbreak situation from epidemiological week 18 to week 23 and then from week 30 to week 53. Historically, Choco, Nariño, and Antioquia remain the departments with the highest incidence of the disease [14]. The year 2021 showed a decrease of 11.4% with respect to the previous year, with a total of 70,838 cases reported. 14 municipalities reported outbreak situations. During this year, 1291 cases of coinfection between malaria and COVID-19 were reported [14].

3. Community-based knowledge and actions regarding malaria

From a cultural perspective, the health system is made up of hierarchies or levels: the popular, the folkloric, and the professional level. An approximation among the three represents pluralism in the healthcare of a particular social group [21].

The so-called third sector, or professionals, has a technical language that separates it from their patients—their own body of knowledge. It emphasizes on the disease and is often based on technology. This perspective applies both to health care and to the generation of policies, plans, and programs that are vertically established, ignoring the conception of local medicine, which is part of a larger system of beliefs, behaviors, and attitudes.

It is important to emphasize that part of the verticality with which most health programs are established originates from this hierarchical sectoring specific to the area’s staff. Knowledge and training, different from those of the community, create a gap that separates them. The community that “does not know” can be diagnosed and treated because its cultural baggage is not recognized as it is another type. In addition, this alleged “superiority” leads to a paternalistic treatment, a position generally adopted in relation to vulnerable communities.

These views of what the community is, from a professional perspective, draw disease prevention, treatment, and control paths, which are often parallel and have no contact between them. Thus, the community perspective needs to be incorporated into institutional programs. Programs are designed with no participation from the communities involved, ignoring local knowledge and the socio-political and cultural dynamics around their main health problems, in this case malaria. This leads to imposing out-of-context control measures that reduce the coverage and impact of interventions [12].

4. Malaria control programs in America

Because malaria transmission is highly heterogeneous, control programs in the Americas have to adapt to these different environments [22]. Reactive strategies are the most feasible ones and are endorsed by the World Health Organization [23]. Reactive case detection (RACD) tests and treats all household members related with a positive malaria case detected in a health facility; sometimes the neighbors are also treated [24]. Other strategies try to test the whole community that has at least one diagnosed case; this strategy is called mass screen and treat (MSAT). Or they test the whole population even if there is not a confirmed case of malaria, called mass test and treat (MTAT) [25]. The best strategy depends on the resources and their objectives, and these activities have to be attached to an effective vector control program and a strong health system [26].

5. Malaria control programs in Colombia

Since the dawn of the twentieth century and during the time of public hygiene, malaria as well as anemia produced by uncinaria have been considered disease control priorities, because they affected those areas where the production of coffee and oil began to be fundamental to the economy of the country [4].

The public health programs that marked the beginning of the twentieth century were designed from the perspective of the control and power that dominated the context of the new century. Europe was uniting at the expense of great wars, and the eyes of the great powers turned to Latin America’s resources for the reconstruction of their economies. International health agencies were born in response to the need to control the prevailing tropical diseases in which North American companies began to reap benefits from the newly discovered products, channeling the expansion of the exchange in the Americas under civilizing, modernizing, and hygenizing slogans [27].

Between 1956 and 1983, a vertical control program was carried out in the country headed by the Ministry of Health’s Direct Campaigns Directorate and the Malaria Eradication Service (SEM by its Spanish acronym), a program that ran parallel to the National Health System [5], and it stood out for its warmongering conception of the disease with a marked use of military terminology [28].

This period was marked by the implementation of the strategy of the Pan-American Health Organization (now known as PAHO), which in the face of communicable diseases such as yellow fever and malaria focused its activities on eradicating the vector and, consequently, the disease, introducing the use of residual-acting insecticides (DDT: dichloro-diphenyl-trichloroethane), which were initially used as pediculicide against a typhus epidemic in Naples between 1943 and 1944. The objective of the campaign was to achieve the eradication of malaria throughout the national territory, and it was carried out in four phases: preparatory, attack, consolidation, and maintenance phases [27].

During the 1980s and 1990s, there were profound reforms to the health system. Between 1983 and 1990 and in line with the State decentralization reforms, the program went from being run by the nation to the being run by the departments [29]. Between 1991 and 1994 and specifically after Law 100 of 1993, the programs run by the State ended, transforming the fight against malaria into a control program with several stakeholders dividing malaria control activities into collective actions (headed by the State) and individual actions (headed by health insurers) [7].

From the market perspective of the health system in force since 1993 and with the corresponding loss of control on the part of the state, malaria management programs have deteriorated due to the fragmentation of actions, leading to the loss of information due to the lack of robust data-gathering and analysis systems, the dismantling of the diagnostic capability installed, and the deterioration of the indicators of disease control [6]. During 2010–2015, the “Malaria Project” was carried out, with the general purpose of reducing malaria morbidity and mortality in the departments, with the highest concentration of cases in Colombia. The objectives were aimed at designing and implementing communication and social mobilization plans to increase protective factors [30]. However, none of the departments involved in our study were within the Malaria Project action plans.

6. Malaria control, prevention, treatment, and access issues in rural communities

Diseases such as malaria mainly affect populations under poor socio-economic conditions, living in precarious housing, with limited access to basic public utilities such as potable water and basic sanitation; under deteriorated environmental conditions; and with barriers to access health services. Other human activities that foster population movements, such as migration and wars, lead to the spread of both the parasite and the vector. Generally, these vulnerable populations live in rural or peri-urban areas [16]. High prevalence of this disease diminishes economic growth and perpetuates the vicious cycle of poverty. Rural areas are the most vulnerable since buildings and poor housing facilities have very little or no protection against mosquitoes [8, 10]. In Panamá, malaria cases have progressively increased in prevalence in the past 20 years. Factors such as a weak control program have affected the indigenous settlements in a major proportion [31].

In Colombia, housing conditions and basic needs are very variable; in the Olaya Herrera municipality (Pacific region), only 33.6% of the population has aqueduct, 8.2% has sewerage, and 65% has garbage collection [32]. In Vista Hermosa (a hilly landscape and alluvial plains area of the eastern plains), electrical services coverage is only 89%, and the garbage collection service reaches 85%. A similar percentage of coverage is found in the aqueduct and sewerage services, reported only by 78% of the inhabitants. Similar conditions are evident in San Jose del Guaviare (transition area between the Orinoquia and Amazon regions), where the water supply service reaches only 60% of these communities and the sewerage service reaches 53.4%. Likewise, garbage collection reaches 87.4%. Overall, these conditions have led to a significant deterioration of environmental conditions, and the population’s low awareness of these issues adds to these issues. In many areas of the municipalities, garbage can be seen on the streets and water source contamination is very evident.

Child mortality from malaria could be reduced by up to 20% if people were to sleep under insecticide-treated (mosquito) bed nets. Fast access to effective treatment can further reduce deaths. Intermittent preventive malaria treatment during pregnancy can significantly reduce the proportion of low-birth-weight babies and maternal anemia [8].

In Colombia, the provision of health services in dispersed rural areas is hampered due to the geographical isolation of many communities; distances and topographic difficulties of the terrain make entering these areas difficult. Public order issues due to the presence of participants of the armed conflict do not allow the approach and adequate provision of health services. In remote rural areas of the country, quality of life indicators lag behind. There are reports of high fertility; high infant and maternal mortality rates; low life expectancy; high levels of malnutrition; low levels of schooling; high illiteracy rates; and low levels of basic sanitation services coverage for potable water, sewerage, and electricity in the population. On the other hand, ethnic groups with different cultures, knowledge, and activities related to health issues, with a greater emphasis on the ancestral medicine of their communities, predominate in these areas, which poses a challenge to their healthcare [9].

7. Knowledge, attitudes, practices, and intervention related to malaria in Colombia

Since it is one of the most malaria endemic areas, several studies have been carried out in the Pacific to implement and evaluate strategies to improve the quality of life there, starting with the reduction of malaria cases in communities. Educational strategies can improve prevention practices in communities, and this is reflected in the decrease in the incidence of malaria cases in the areas under intervention [33]. In addition, the inclusion of educational strategies integrated in national control program activities leads to a decrease in institutional costs and a reduction in cases [34].

In the municipality of Bahia Solano, it was discovered that more than 70% of the people surveyed know that malaria is transmitted by a mosquito bite. However, about 55% do not go to a health center for treatment but take herbal infusions or baths prepared with plants [35]. In the municipality of Olaya Herrera, 61% of the people surveyed claimed to have contracted malaria, and 75.37% considered the disease a problem for them and their families [32].

In the eastern plains, in the municipality of Vista Hermosa, 43% of respondents reported having had malaria at some point in their lives, and 90% still consider this disease a problem for themselves and their families. In terms of knowledge about the disease, 63% recognized that a mosquito is the vector of malaria, although they did not specifically identify which mosquito it is. In the municipality of San Jose de Guaviare, 59% of respondents said that they had malaria at some point in their lives, and 16.5% do not consider malaria a health problem for themselves and their families. 76% knew that the disease is transmitted by any mosquito bite, and only 6% knew that the Anopheles mosquito was specifically the vector of this pathology.

Despite growing community awareness of the way in which the disease is transmitted, they have no confidence in care centers. 38.7% of respondents said that they did not receive good care from health officials when they were suffering from malaria, while 90.98% of those who had malaria went to health centers and followed the treatments prescribed by doctors. 43% claimed that the office of the secretary of health makes no effort to reduce malaria in the municipality, and 51% said that there is no malaria awareness education [32]. In Vista Hermosa, most of the disease control actions are individual, among which are the drainage of lagoons and ponds at 32% and the use of bed nets (mosquito nets) at 74%. None of the respondents reported using household awnings to prevent mosquito entry, only 9% said they sprayed their homes with insecticides, and 10% used repellents.

It is possible that disconnection between communities and government agencies may be influencing malaria control programs so that they are not very ineffective.