Abstract

Context: One of the key objectives of the WHO’s “Global Technical Strategy against Malaria 2016-2030” is to eliminate malaria in at least 30 countries by 2030. However, it has to be said that malaria is progressing dangerously in some of the 21 priority countries, including Burkina Faso, which complicates the achievement of the elimination objectives. Objective: The aim of this study was to assess documented good practices that are conducive to malaria intervention and elimination. Method: We searched Medline, Cochrane, Hinari, Global index Medicus and Google scholar for relevant studies published between 2016 and 2023, and produced a narrative synthesis to organize and categorize the various interventions. Data quality was assessed using the Dixon-Woods M technique and risk of bias using the Cochrane’s ROBINS-I assessment tool. Result: A sample of 41 documents was selected to meet our assessment criteria. The 7 good practices conducive to malaria elimination are the use of long-lasting insecticide-treated nets (LLINs), combined interventions, mass drug administration (MDA), chemoprevention of seasonal malaria (CPS), intermittent preventive treatment of malaria (IPT), rapid diagnostic testing, and antimalarial treatments. Conclusion: This review has identified good practices conducive to malaria elimination of malaria. However, other innovations such as gene drives and vaccines are interventions which, when combined with these good practices, could enhance the efforts of health programmes in our African countries.

Keywords

Malaria, Intervention, Elimination, Control, Treatment, Malaria Control

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1. Introduction

Malaria is an endemic disease in 83 countries, contributing to about 263 million cases and over 597,000 deaths worldwide in 2023 [1]. Although the epidemiological burden of malaria has been considerably reduced, it remains the world’s leading cause of morbidity and mortality. One of the key objectives of the WHO’s “Global Technical Strategy against Malaria 2016-2030” is the elimination of malaria in at least 30 countries by 2030. To support this goal, WHO launched the E-2020 initiative in 2017, which brought together 21 countries with the potential to achieve zero cases of malaria by 2030. Burkina Faso is one of the ten most affected countries worldwide (3.4% of cases and 3.2% of deaths worldwide in 2020). The country experienced a 17.3% drop in the incidence rate between 2016 and 2019, from 0.87 to 0.72 per 1000 inhabitants at risk [2]. This trend is particularly significant in Africa, where nearly 94% of deaths are malaria-related (WHO Malaria Report 2024) [3].

To address with the burden of the disease, health authorities in many endemic countries, following WHO guidelines, have implemented several anti-malarial programmes and strategies within health facilities and communities. These include the use of long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS), seasonal malaria chemoprevention (SMC), intermittent preventive treatment (IPT), artemisinin-based combination therapy (ACT), and malaria diagnosis and treatment as measures aimed at reducing morbidity and mortality in the population [4]. Other interventions include malaria vaccines, vector control via drone spraying, epidemiological surveillance, repellents, integrated vector management, and gene drive technology.

These efforts have contributed to a reduction in malaria-related deaths from 805,000 to 569,000 (2000 to 2023) [3]. However, despite this progress, the burden of malaria has remained very high and the rate of has begun to stagnate, jeopardizing the achievement of the 2030 targets. One of the concerns is the development of resistance to antimalarial drugs, which hampers the improvement of antimalarial interventions [5]. Another concern involves political changes affecting antimalarial strategies in terms of funding, governance, innovation and adherence to public health programmes [6].

All these innovations and strategies should be the subject of a comprehensive review. Little is known about these good practices in the scientific literature, yet understanding them could shed light on community, economic and health issues, underlining the need to continue the efforts undertaken by governments and communities who find themselves powerless against this disease.

A number of research studies have been carried out on various malaria-related topics. However, an evaluation of the different interventions, whether they are individual, combined or used as a complement to other strategies, through a systematic review and in comparison, with other existing reviews, will better situate this study within the current body of knowledge. This approach will provide endemic countries with a concrete tool to advance progress in the fight against malaria.

2. Methods

The systematic review protocol was registered in PROSPERO under number CRD42024587238.

The review was carried out in accordance with PRISMA guidelines [7]. The primary research question was: What documented good practices are conducive to malaria intervention and elimination?

2.1. Inclusion and Exclusion Criteria

The PICO(S) strategy was adopted for this research to formulate a well-defined, clear, targeted and precise research question [8]. This strategy consists of:

P: (Population): ‘Population of endemic countries; I: (intervention): “effective interventions” “Malaria strategy” “malaria prevention” “malaria treatment” “diagnosis of malaria” “malaria elimination” “malaria vaccine” “fight against malaria”; C (comparison): “Absence” “ineffectiveness of similar interventions in endemic countries”; O (out com): “Reduction” “elimination of indigenous malaria cases”; S (setting): “Observational studies”, “controlled trials”, “qualitative studies”, “WHO reports”, “existing reviews”.

Eligible studies had to meet the following criteria: be a publication detailing elimination strategy in malaria-free countries and their potential adaptation to endemic regions; use a qualitative, quantitative or mixed method; be a study published in peer-reviewed journals or institutional reports (WHO, UNICEF, etc.); be written in English or French; report on the period from 2016 to 2023.

Studies that did not meet the inclusion criteria and articles that focused solely on interventions unrelated to malaria were excluded.

2.2. Search Strategy and Study Identification

Two independent investigators (DO, AK) conducted searches across the electronic databases of PubMed, Cochrane, Hinari and Global index Medicus, as well as the grey literature via Google scholar. The search used qualitative, quantitative or mixed methods, and included studies published between 2016 and 2023, aligning with the WHO’s call for countries to adopt strategies toward achieving the 2030 goals. In addition, a manual search on each malaria intervention was performed to complete the analysis.

These strategies yielded 2630 articles after removing duplicates. Keywords were applied to titles, abstracts, and full texts during screening. Reading the title to eliminate irrelevant documents was the first step in the selection process. A preliminary set of 284 documents was retained at this stage. Various disagreements regarding inclusion were resolved through discussion among all the investigators. When title and abstract information were insufficient for decision-making, full-text reading was performed to resolve the issue.

Two investigators individually extracted the data from each study meeting the criteria, using standardized forms designed to synthesize the results. A third investigator (HH) was consulted in case of discrepancies. The following data were extracted: Author, Year of publication and study, Country/continent, Type of study, Type of interventions, and Main results (Table 1).

2.3. Data Collection and Analysis

We used the technique based on narrative synthesis, according to Petticrew and Roberts, to categorize studies according to different interventions and innovative actions in malaria control (Table 1) [9].

2.4. Determining Document Quality and Risk of Bias

Determination of document quality was borrowed from the National Health Service (NHS) criteria of Dixon-Woods et al. (Table 2) [10]. Risk of bias was assessed using the ROBINS-I risk-of-bias assessment tool (Table 3) [11]. This identified the strengths and weaknesses of the studies, as well as implications for the review’s conclusions and recommendations.

3. Results

Finally, 41 studies were assessed for their methodological merits and included in the analysis. A flow chart illustrating the selection process is presented below (Figure 1).

3.1. Descriptive Results of Eligible Studies

At the end of this research, we observed seven good practices (Table 1):

• LLINs, observed in 3 studies in Rwanda, Congo and Benin. The studies by Kabera et al. reported a 71% reduction in malaria cases [12]. While Accrombessi et al. found a 66% reduction in the entomological inoculation rate [14]. This result is attributed to the high coverage of LLINs in the area, and their protective effect in reducing the number of new infections.

• SMC, identified in 4 studies in Mali, Ghana, Uganda and Sudan. Boyce et al. observed a 53.4% reduction in the incidence of malaria [30]. This result is similar to that of Molina-de la Fuente et al., who reported a 53% reduction [33]. As for Issiaka et al. and Adjei et al., a 66% reduction in morbidity and mortality was observed [31] [32].

• MDA found in 2 studies in Cambodia, Eswatini. The studies by Tripura et al. observed no clinical cases of malaria after MDA [38]. Vilakati et al. reported a 74% reduction in the incidence of malaria [39]. These results suggest that MDA has had a significant impact on malaria transmission in these regions.

• IPT, observed in 5 studies in Ghana, Cameroon, Malawi, Uganda and Tanzania. These studies reported a treatment efficacy of 95% [28] [29], and a reduction in low birth weight [25] [27].

• RDT, identified in 1 study in India, with a sensitivity of 49.9% and a specificity of 90.4% [40].

• Antimalarial treatments, found in 5 studies. The results of these studies are similar in the treatment group for uncomplicated malaria, with 98% efficacy [41]-[43], and in the severe malaria group, where the cure rate is over 98% [47] [48].

• Combining interventions, identified in 5 studies in Ghana, Uganda, Namibia Thailand and Mozambique. The outcomes of these combinations varied by region, but led to a reduction of malaria incidence ranging from 38% to 75% [18]-[22].

3.2. Quality Assessment Results

A total of twenty-seven (27) studies obtained a score of 5/5, nine (9) a score of 4/5 and five (5) a score of 3/5 (Table 2).

Nineteen (19) studies had a high risk of bias, seven (7) had a moderate risk and fifteen (15) had a low risk (Table 3).

Figure 1. Flow chart for the identification and selection of articles included in this review.

Table 1. Summary of selected reviews.

Table 2. Quality evaluation results.

Table 3. Results of risk of bias assessment.

4. Discussion

This review identified seven (7) best practices in malaria control: LLINs, SMC, mass drug administration, IPT, rapid diagnostic testing, antimalarial treatments, and combined interventions. We have also observed other practices and perspectives that can play a crucial role in this fight. In this section, we will examine the impact of each of these interventions, identify their limitations and propose solutions to optimize their effectiveness.

The use of long-lasting insecticide-treated mosquito nets (LLINs): This is one of the most effective interventions in the fight against malaria. Kamau et al. (2022) and Barker et al. (2023) respectively reported a significant protective effect of 47% and a 53% reduction in the incidence of malaria cases after intervention in the population [53] [54]. This could be explained by the fact that LLINs kill or repel mosquitoes, preventing the bites of malaria-vector mosquitoes and reducing the density of mosquito populations. However, their limited lifespan (3 to 5 years), inadequate coverage in inaccessible areas and the emergence of insecticide resistance in mosquitoes hamper their effectiveness [13] [55]. It is therefore necessary to continue investing in research on new-generation LLINs, and to improve supply chains by using, for example, drones or partnerships with local organizations.

Mass drug administration (MDA): This shows very promising results in the fight against malaria. Li et al. demonstrated the effectiveness of this strategy in their study, reporting an 87.2% reduction in parasitaemia and an 89% reduction in malaria cases in the community after the campaign [56]. This success could be explained by the fact that MDA promotes a rapid reduction in parasite load and provides post-treatment protection through the prophylactic effect of drugs like dihydroartemisinin-piperaquine. Schneider et al. (2024), in turn, observed that MDA is only effective between 1 and 3 months after intervention, with a 39% reduction in the incidence of parasitaemia, and little or ineffective beyond the fourth month [57]. This could be attributed to the emergence of drug resistance hindering its efficacy, and to incomplete coverage leading to retransmission of parasites through untreated people. To address these challenges, it is essential to strengthen epidemiological and resistance monitoring, and to alternate drugs to reduce resistance.

Seasonal malaria chemoprevention (SMC): SMC has played a major role in malaria control. Cairns et al. (2021) and Manga et al. (2022) observed a protective efficacy of SPC against malaria of 88% and 89% respectively [58] [59]. However, this strategy is limited by drug resistance, incomplete coverage, and logistical and financial challenges that hinder enrolment and follow-up due to logistical and financial constraints. To overcome these obstacles, it is essential to step up awareness campaigns, optimize distribution logistics to ensure that targeted children receive treatment on time, and strengthen the resistance monitoring system.

Intermittent preventive treatment of malaria (IPT): This has played a major role in the control of malaria in pregnant women (IPTg), infants (IPTIn) and children (IPTs). Kamau et al. (2022) found that IPTg was associated with a 21% reduction in stillbirths [60]. Similarly, Maiga et al. (2022) found a 67% and 55% reduction in the risk of P. falciparum infection after two cycles of full treatment with sulfadoxine-pyrimethamine or amodiaquine plus artesunate in schoolchildren aged 6 to 13 [61]. Indeed, IPTs prevent symptomatic infection by killing parasites as soon as they are introduced into the organism, reinforcing its protection against the disease. However, their effectiveness is limited by drug resistance, incomplete coverage, poor adherence to treatment, as well as financial and logistical constraints. There is a need to reinforce resistance monitoring, step up awareness campaigns, strengthen supply chains to ensure regular distribution, and encourage research into new therapeutic molecules.

Rapid Diagnostic Test (RDT): It has played a crucial role in the fight against malaria by rapidly detecting the presence of Plasmodium infection without laboratory equipment, reducing unnecessary treatment. Ruizendaal et al. (2017) in Burkina Faso observed a sensitivity of 81.5% and a specificity of 92.1% achievable by community health workers [62]. However, RDT is limited by its lack of accuracy for certain Plasmodium species (vivax) and low-parasitemia infection. It is crucial to develop multi-antigen RDTs to improve its accuracy.

Antimalarial treatments: artemisinin-based combination therapy (ACT) and artesunate have played a major role in reducing the burden and transmission of malaria. The results of Shibeshi et al. (2021) testify to the efficacy of ACT, with overall cure rates ranging from 92.2% to 97.4% between days 28 and 63 post-intervention in pregnant women [63]. Byakika-Kibwika et al. (2018) found that intravenous artesunate required an average of 2 days for complete parasite elimination in children [64]. However, artemisinin drug resistance, non-compliance with treatment and limited access due to high costs hamper its effectiveness. It is crucial to strengthen resistance monitoring, increase access to drugs and explore new treatment prospects.

Combining interventions: This approach has shown favorable results in the fight against malaria. The study by Gari et al. (2024) revealed a 37% reduction in the incidence rate following the combination of ITN+IDP within households [65]. Similarly Camponovo et al. (2019) revealed a possibility of malaria elimination in a simulation on the combination of RTS, S vaccine and MDA [66]. Indeed, this strategy makes it possible to integrate the individual advantages of each intervention while overcoming their individual weaknesses. However, this strategy is limited by the resistance provoked by this combination and the extremely high cost of its implementation. It is therefore necessary to optimize resources by targeting interventions in high-risk regions and periods.

Other interventions:

Integrated Vector Management (IVM): IVM, through IRS, has played a favorable role in vector control and the control of mosquito populations [23]. This strategy has been implemented in several countries. According to Zhou et al. (2022), IRS is associated with lower rates of malaria infection (OR = 0.35, 95% CI: 0.27 - 0.44) [67]. Similarly, Tiedje et al.(2022) observed a more than 90% reduction in the monthly rate of entomological inoculation after IRS in participants of all ages [68]. This is because IRS rapidly eliminates infected mosquitoes before they can bite, thereby reducing the risk to individuals. However, this intervention has been abandoned in some African countries due to its extremely costly implementation, the emergence of resistance due to its continuous use, the side effects (respiratory ailments, neurological disorders and developmental delays in infants), as well as its negative impact on the environment after intensive use [69] [70]. The use of drones for malaria surveillance and malaria vector management can reduce costs and strengthen this intervention [49]. Research into new insecticide compounds can also reinforce this strategy.

The RTS, S vaccine: This is a new vaccine that has been introduced and has shown favorable results in the fight against malaria. The study by Cairns et al. (2022) observed an overall protective efficacy of at least 60% over 6 months in children under 5 years of age after the primary series and the two seasonal booster doses. However, efficacy seems to diminish rapidly beyond 6 months of intervention [71]. This could be explained by the fact that the vaccine exerts a certain selective pressure on the parasite, which can lead to mutations, thus affecting its efficacy. Another reason could be that the vaccine is only effective against clinical malaria (P. falciparum). To maximize its impact, it is necessary to combine it with other antimalarial interventions, and to encourage the development and improvement of antimalarial vaccine formulations.

Other prospects in the fight against malaria: Gene drive technology, which modifies the gene in mosquitoes to make them incapable of transmitting the plasmodium parasite, also has enormous potential for reducing disease transmission [37] [38]. Burkina Faso, Mali and Uganda are pioneers in the application of gene drive against malaria mosquito vectors through the Target Malaria project [72]. However, its implementation raises ethical, ecological and social issues. Gene drive is a technology with irreversible effects that requires in-depth studies before implementation, as its introduction could be uncontrollable. Its application raises major questions, particularly about public acceptance and the way in which it will be regulated at international level. Furthermore, it is impossible to predict with certainty whether these mosquitoes will not lead to involuntary mutations that could disrupt the ecosystem, with unforeseen consequences for biodiversity. Finally, this technology may give rise to reticence and concern among certain populations because of cultural, religious or historical beliefs [34].

The R21/Matrix-M vaccine also represents a major advance in the fight against malaria, having demonstrated efficacy of over 75% against malaria [52]. Its implementation may give rise to concern and reluctance among certain populations, influenced by their cultural and religious beliefs. In addition, the introduction of the vaccine may modify the ecology of the plasmodium parasite and lead to resistance [52] [73].

Compared with the systematic reviews by Loeffel et al.(2022) and Kim et al. (2021) analyzing the impact and effectiveness of malaria interventions [74] [75], This review highlights the impact and importance of these strategies for endemic countries. It emphasizes that most interventions target children under the age of 5, pregnant women and the general population regardless of age. A combination of these interventions can have a significant impact. However, this requires, on the economic level, sufficient and sustainable financial availability to carry out these interventions; active involvement of the local community on the social level to carry out the activities; on the political level, strong political commitment to regulate and support malaria control programmes; and on the environmental level, continuous environmental monitoring to combat resistance.

5. Study Limitations

The majority of the studies included are observational, favoring the existence of publication bias, limiting the ability to draw more generalizable conclusions. This underlines the importance of carrying out a meta-analysis to obtain more generalizable results.

6. Conclusion

The present study has enabled us to identify and analyze interventions likely to be effective in eliminating malaria. These insights will enable researchers, programme managers, policy-makers and administrators to identify best practices for malaria elimination, with the aim of optimizing the use of available resources.

Authors’ Contributions

All authors cited in this article contributed to the realization of this study and to the drafting of the manuscript.

Availability of Data and Equipment

All data is accessible to the public. They can be consulted via databases (PubMed, Cochrane, Global index Medicus, Google scholar and Hinari).

Acknowledgements

We thank all colleagues who offered advice and technical support during the writing of this manuscript.

Conflicts of Interest

The authors declare no conflict of interest.

References