Malawi

Malaria Facts 

Malaria is endemic in more than 95% of Malawi. Transmission is perennial in most parts of the country and peaks after the start of the annual rains that typically begin in November/December and last through April. [1]  The highest transmission areas are found along the hotter, wetter, and more humid low-lying areas (lakeshore, Shire River Valley and central plain), while the lowest risk areas fall along the highlands of Rumphi, Mzimba, Chitipa and Kirk Range. [1] 

Plasmodium falciparum is the predominant species of malaria in Malawi, accounting for 95% of malaria infections and all severe disease and deaths. Anopheles gambiae s.s, Anopheles funestus and Anopheles arabiensis are the major malaria vectors. [1]  Malaria continues to be a major public health problem and is responsible for approximately 7 million cases and 36% of outpatient visits across all ages (2020 Health Management Information System [HMIS] data).  

Malawi is among the top 20 countries with the highest malaria prevalence and mortality rates – in 2021, it accounted for 1.7% of global cases , and 1.2% of global malaria deaths. [1] About 8% of all malaria cases in Eastern and Southern Africa occurred in Malawi in 2021. [2]  

Since 2006, Malawi has seen improvements in prevention coverage (insecticide-treated mosquito net [ITN] ownership and use and intermittent preventive treatment for pregnant women [IPTp] uptake), a 48% decrease in all-cause mortality in children under five years of age, and a decrease in malaria prevalence among children under five years of age from 43% (2010 Malaria Indicator Survey [MIS]) to 24% (2017 MIS). [1] 

Between 2020 and 2021, the case burden for malaria stagnated at 219 per 1000 of the population at risk, while deaths fell by 2.7% from 0.38 to 0.37 per 1000 of the population at risk. [2] 

Case Management 

The National Malaria Control Programme’s (NMCP’s) Guidelines for the Treatment of Malaria in Malawi were updated in 2020. Parenteral artesunate is recommended as definitive treatment of severe malaria, and children weighing less than 20 kilograms are treated with a higher dose of injectable artesunate (3 mg/kg) than larger children and adults (2.4 mg/kg). 

Pre-referral intervention for suspected severe malaria is recommended in peripheral health facilities using intramuscular artesunate in adults and children, and at the community level using rectal artesunate in children under six years of age. [1] 

According to the 2017 MIS, 21% of patients with fever seek treatment in the private sector. The national policy allows testing and treatment to occur in the private sector; artemether-lumefantrine (AL) is the first line treatment with artesunate-amodiaquine (ASAQ) as a second line option. Dihydroartemisinin-piperaquine (DHA-PQP) is registered in Malawi and is estimated to comprise ~5–10% of treatments in the private sector. [1] 

Prevention of Malaria in Pregnancy 

There has been a steady increase in the overall uptake of intermittent preventive treatment for pregnant women (IPTp) in Malawi; however, uptake of at least 3 doses of IPTp (IPTp3) remains low.  The percentage of women receiving at least one dose of IPTp increased from 77% in 2012 to 92% 2017. The percentage of women receiving two or more doses of sulfadoxine-pyrimethamine (SP)/Fansidar® for IPTp2 and IPTp3 increased from 54% in 2012 to 76% in the 2017 and from 13% in 2012 to 41% in 2017, respectively. 

Malawi aims to increase uptake of at least 3 doses of IPTp due to late initiation of antenatal care (ANC) through innovative interventions, including the introduction of community-based IPTp. The malaria programme aimed to conduct a pilot study in 2020 on the feasibility, acceptability and effectiveness of using Health Surveillance Assistants (HSAs)  for community IPTp distribution.[3] 

Malaria among Schoolchildren 

Primary schoolchildren in Malawi have a high risk of Plasmodium infection, and a high prevalence of asymptomatic infection. Malaria infection in this population can lead to increased morbidity, reduced school attendance and delayed cognitive development, so Malawi has introduced malaria case management in schools through the Learners Teachers Kit project in Zomba and Machinga, and planned to expand the malaria case management program to primary school-children in selected schools in 4 districts in 2021. A minimum of two teachers, at least one male and one female in addition to the head teacher will be trained and supplied with an LTK Kit which will include malaria Rapid Diagnostic Tests (mRDT)s and Artemisinin-based Combination Therapy (ACTs) for testing and treating malaria cases.[3]  According to the 2017 MIS, prevalence of malaria in urban areas and rural areas is 4% and 30%, respectively [3]. 

Insecticide Treated Nets (ITNs) 

Households owning at least one ITN increased from 38% in 2006 to 82% in 2017. (It should be noted that the 2017 Malaria indicator survey (MIS) was conducted in April, just before the October mass distribution campaigns, so does not reflect peak coverage.) While the majority of households own at least one ITN, there may not be full coverage of all household members. 

ITN use among children has generally increased from 2006 and remained steady with a high of 68% according to the 2017 MIS. ITN use among pregnant women has tracked similarly, with a high of 63% according to the 2017 MIS. [1]