Running head: MALARIA IN THE GAMBIA 1

Malaria in The Gambia

Ndey Tabara Khan

Western Washington University

Nursing 452: Global Health

Dr. William Lonneman

March 9th, 2017

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Malaria has gained the spotlight worldwide due to the devastating effect it has on

particular regions of the world. The World Health Organization (WHO) estimates released in

December 2016 indicate that there were 212 million cases of malaria worldwide in 2015 and

429,000 deaths. The Sub-Saharan Africa region suffered the highest proportion of the malaria

burden with about 90% of malaria cases and 92% of malaria deaths occurring there (WHO,

2016). Among those cases studies show that children under five and pregnant women are more

susceptible to the malaria infection, illness and even death. According to the WHO (2016), about

70% of all malaria deaths were those of children under the age of 5. The purpose of this paper is

to identify the presence of malaria in a Sub-Saharan African country, The Gambia. The paper

will discuss the successes and challenges the country has in the fight against malaria, offering

alternatives and evidence based recommendations in the fight against malaria.

The Problem and its Significance

The Gambia is one of the smallest counties in West Africa, surrounded by Senegal and

the Atlantic Ocean. The ecosystem of The Gambia is tropical forest along the banks of the River

Gambia and along the coast, while inland the climate is more semi-arid savannah or sahel

(Republic of The Gambia- Department of state for health and social welfare [DoSHSW],

2009). According to WHO (2015), The Gambia has a population of 1,991,000 million people.

As with most Sub-Saharan African countries, The Gambia is among the low-income developing

countries in the region. It has a Gross Domestic Product (GDP) per capita of $1,555 as of 2015

according to the Institute for Health Metrics and Evaluation (IHME). Forty-eight point four

percent of its citizens live in poverty, with 50% adult literacy (The United Nations Development

Programme [UNDP], n.d.) and life expectancy of 66.7 for males and 69.6 for females (IHME,
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2015). In The Gambia, malaria is one of the leading causes of death among children and

pregnant women, causing 40% of deaths among hospitalized patients in those groups (Ceesay,

2014). The primary reason for this is that The Gambias climate is highly favorable to the

malaria parasite. The primary carrier of the malaria parasite, the female Anopheles mosquito,

favors humid and warm climates where pools of still water can be found for the larvae to mature.

The mosquito also thrives where general levels of education and awareness are low, and where

the health care system is less than optimal (United Nations International Children's Emergency

Fund [UNICEF], 2000).

Malaria is a seasonal disease in The Gambia. Although it occurs throughout the year, it is

most prevalent during the rainy season. Over 90% of clinical cases of malaria are transmitted

during the rainy season, which lasts from June through October. 80% of the most severe cases

occur during October and November alone. The rural areas of the country are hit the hardest,

because there are fewer habitats available for the mosquitoes to breed in the urban areas. The

rural eastern part of the country has several factors that make it attractive to the mosquitoes, such

as rice irrigation, flood planes and swamps (DoSHSW, 2009).

Achieved success in the fight against malaria in The Gambia

The Gambia has a strategic plan in the effort to fight malaria in collaboration with local

and international Non-Governmental Organizations (NGO). The Medical Research Council

(MRC) is one of the leading NGO hospitals in The Gambia. In partnership with the National

Malaria Control Programme, UNICEF, WHO, the Global Fund, and other organizations, they

claim that malaria has significantly declined in The Gambia due to the combined efforts of

distribution of insecticide-treated nets, indoor residual spraying, effective drug combinations,

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intermittent preventive treatment in pregnant women, and environmental sanitation (MRC,

2008).

These claims are backed up by statistics; in 2002 there were approximately 600,000 recorded

cases of malaria in The Gambia, while in 2004 this was reduced to 200,000. This is due to the

fact that awareness is spreading, people are being diagnosed earlier and more accurately, and

vulnerable groups are receiving targeted attention. Additionally, insecticide-treated bed nets are

being used by 63% of the population (Reed, 2005).

In the strategic plan to control malaria there are other tools that are being used. These

include targeted larviciding, indoor residual spraying, environment management, and

reproductive health and child clinics. The first universal campaign was conducted in 2011.

Another mass campaign was done in May 2014 to attempt to achieve the universal coverage

targets, with over 1 million insecticide-treated nets distributed (Ceesay, 2014). In indoor residual

spraying, coverage rates reached 80% in 2013, with 62% of children under five sleeping under

long lasting insecticide nets as opposed to 66% of the general population.

It is important for one to seek medical attention and receive treatment as soon as possible

once diagnosed, because malaria can be very deadly. In the anti-malaria drug categories,

Chloroquine used to be the drug of choice for the malaria disease, but in recent years, studies

show that the P. falcipaparum mosquitoe has built up resistance to the drug. Consequently,

malaria treatment in The Gambia has switched from Cholorquine to a new drug therapy called

Artemisinin Combination Therapy (ACT) (Ceesay, 2014). In clinical trials, success rates for this

drug reached up to 95% (Azadeh, 2015). This is a very promising trend that gives the fight

against malaria a great deal of hope.

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The malaria campaign in the Gambia has had some success through the implementation

of the strategic plan of 2008-2015 by distributing long lasting insecticide nets, indoor residual

spraying, encouraging environmental cleaning, and providing the most recent drug therapies to

the most at-risk population in The Gambia. As a consequence of this massive effort, the rate of

malaria parasite infection in children ages 6-59 months is down to 4%. For the population as a

whole, instances of malaria dropped by 85%, hospital admissions from malaria infection dropped

by 74%, and malaria-related deaths dropped 90%. Furthermore, infant mortality dropped 32%

(Ceesay, 2014). Even with all of this success, there are still some challenges that need to be

addressed in the fight against malaria.

Challenges in the fight against malaria

The Gambia faces many challenges in its efforts to eradicate malaria. According to

Ceesay (2014), financial barriers are among the obstacles to continue the fight against malaria.

The parasites have developed resistance to anti-malaria drugs, and a lack of education in the

communities makes adopting behavioral and environmental changes more difficult. The high

cost of the Atemisinin Combination Therapies (ACTs) makes it difficult to attain universal

coverage (Ceesay, 2014).

Despite the significant decrease of malaria in the Gambia, transmission is still occuring.

According to Mwesigwa et al. (2015) there has been little change since 2009 in the reported

prevalence of P. falciparum infection in some villages in The Gambia. This suggests that

although progress has been made, transmission of the malaria parasite is still ongoing. Observed

infection rates approached 50% in some villages in the eastern portion of The Gambia, which is

similar to reported infection rates in other high-transmission areas such as Tanzania, Gabon, or

Burkina Faso.
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This indicates that there is still work needs to be done to eradicate malaria. As pointed

out at the beginning of this paper, the eastern part of the Gambia where rice irrigation is popular,

and also the presence of flood plains and swamps, makes it a strong mosquito breeding ground.

The eastern part of the country is in the rural area, access to health care and prompt treatment is

very challenging, and poverty is a major issue, and these factors contribute to the challenge in the

fight to eradicate malaria in The Gambia.

Another challenging factor The Gambia faces in the fight against malaria is the lack of

adequate diagnostic resources. One of the major problems in eradicating the disease is that

people who are carriers of the malaria parasite often go undiagnosed due to a lack of symptoms.

According to Mwesigwa et al. (2015) large portions of the participants surveyed were

asymptomatic despite testing, which confirmed they were infected. These asymptomatic carriers

make it extremely difficult to eliminate the disease from a vulnerable population because they

can still transmit the disease to others through the vector of the mosquito. Hence there is always

a reservoir of infected hosts despite efforts to treat the symptomatic population. This is further

complicated by the fact that significant portions of malaria infections in the eastern region of the

Gambia are sub-microscopic, which means they would be missed by routinely used diagnostic

tools (Mwesigwa et al., 2015). The lack of adequate diagnostic tools to identify the

asymptomatic carriers increases the prevalence of malaria in The Gambia and makes it even

harder for this disease to be eradicated.

Recommendations

There are two main methods of dealing with malaria. The first is the distribution of

insecticide-treated nets. The second is the early diagnosis and treatment of the disease. UNICEF

(2000) suggests that health aid workers play an extremely important role in both of these
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methods. The health care worker spreads education about the disease within the community,

distributing not only the nets but also the understanding of how and why to use them. This alone

can significantly reduce the mortality rates among the children in a community. The more

knowledge the health worker has, the more they are also able to diagnose and treat those who

have become infected.

There is also a new breakthrough on the horizon in the fight against malaria. Gene-

editing techniques have been shown to have the potential to eliminate the ability of mosquitoes

to transmit malaria to humans. The concept would involve introducing individual mosquitoes

with the edited genes into the general mosquito population, and have those genes passed on to

their offspring, and their offspring, etc. Hopefully after a sufficient number of mosquito

generations have passed, there would be a sufficient critical mass of mosquitoes with the

malaria-blocking genes such that the transmission of malaria would cease to occur (University of

California, Irvine, 2015). This would be a tremendous achievement in the fight against malaria.

WHO (2016) also recommends the routine monitoring of levels of resistance to anti-

malarial drugs. I think monitoring drug resistance to the malaria parasite can help The Gambias

health sector to implement early interventions in this fight. Data on malaria needs to be

continuously tracked and updated, and WHO (2016) recommends a thorough malaria

surveillance program to accomplish the following:

Advocate for investment from domestic and international sources, commensurate with

the malaria disease burden in a country or subnational area;

Allocate resources to populations most in need and to interventions that are most

effective, in order to achieve the greatest possible public health impact;

Assess regularly whether plans are progressing as expected or whether adjustments in the

scale or combination of interventions are required;

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Account for the impact of funding received and enable the public, their elected

representatives and donors to determine if they are obtaining value for money; and
Evaluate whether programme objectives have been met and learn what works so that

more efficient and effective programmes can be designed

Reflection & Conclusion

During my research for this project, I learned that The Gambia has one of the strongest

malaria control program in the sub-Saharan Africa region. They made great progress in the fight

against malaria starting in the early 2000s by providing country wide insecticide-treated nets,

especially to children and pregnant women for free. Encouraging indoor residual spraying,

providing intermittent preventive treatment for pregnant women, targeted larviciding and

environmental management all contributed in their progress to fight malaria. On the other hand,

given that The Gambia is a developing country in the Western part of the African continent, they

still face challenges in the fight against malaria. Lack of adequate resources and funding delays

the eradication of this disease. In order for this country to achieve their goal to eradicate malaria,

the continued collaboration with their partners has to be ongoing, and adequate funding must be

available to overcome the barriers for success to be achieved.

As I learned during this research, the Department of State for Health and Social Welfare

and the National Malaria Control Programme in the Gambia partner with many community-

based, local and internal NGOs in collaboration to meet the WHO global rollback of malaria

targeted for 2016-2030 by:

Reducing malaria case incidence by at least 90% by 2030.

Reducing malaria mortality rates by at least 90% by 2030.
Eliminating malaria in at least 35 countries by 2030.
Preventing a resurgence of malaria in all countries that are malaria-free
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I think The Gambia is a leading example for the surrounding region in Africa in the fight against

malaria. There is no vaccine for malaria as of now, as according to the Center for Disease

Control and Prevention (2015) the malaria parasite is genetically complex and there has been no

luck so far in creating a vaccine against it. However, there is a trial going on in 11 countries in

Africa, and they are hopeful that by 2025 a malaria vaccine will be available. This along with

the previously described gene editing technology might represent the best hopes for eradicating

malaria altogether, an outcome that would be beneficial to the whole world.

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References

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season. Retrieved from http://allafrica.com/stories/201507211673.html

Ceesay, M. (2014). Malaria remains key problem in Gambia. Retrieved from

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