World Malaria Report 2021: Tracking progress against Malaria

Overview

Each year, WHO’s World malaria report provides a comprehensive and up-to-date assessment of trends in malaria control and elimination across the globe. It tracks investments in malaria programmes and research as well as progress across all intervention areas: prevention, diagnosis, treatment, elimination and surveillance. The 2021 report is based on information received from malaria-endemic countries in all WHO regions.

This year’s report at a glance

KEY EVENTS IN 2020–2021
Service disruptions

• In April 2020, during the early months of the coronavirus disease (COVID-19) pandemic, analysis by the World Health Organization (WHO) and partners had projected a doubling of malaria deaths if the worst-case scenario of service disruptions occurred.
• With support from global, regional and national partners, countries have mounted an impressive response to adapt and implement WHO guidance to maintain essential malaria services during the pandemic.
• Overall, most malaria endemic countries experienced moderate levels of disruptions to the provision of malaria services.
• Of the 31 countries that had planned insecticide-treated mosquito net (ITN) campaigns in 2020, 18 (58%) completed their campaigns by the end of that year; 72% (159 million) of the ITNs from the planned campaigns had been distributed by the end of 2020.
• Thirteen of the 31 countries (42%) were left with 63 million ITNs that were initially planned for distribution in 2020 but spilled over to 2021. Among these 13 countries, six (46%) had distributed less than 50% of their ITNs by the end of 2020. By October 2021, only Kenya and South Sudan had not completed distribution of all spillover ITNs.
• Seasonal malaria chemoprevention (SMC) was distributed as planned in 2020, and an additional 11.8 million children were protected with SMC in 2020 compared with 2019, mainly because of the expansion of SMC to new areas in Nigeria.
• Planned indoor residual spraying (IRS) campaigns were also on target in most countries in 2020.
• Overall, survey and routine data suggest that there were moderate levels of disruption in access to clinical services in most moderate and high malaria burden countries in 2020.
• During the COVID-19 pandemic, up to 122 million people in 21 malaria endemic countries needed emergency relief due to other humanitarian emergencies unrelated to the pandemic.

Emergence of partial resistance to artemisinin in the WHO African Region

• Recent evidence of the independent emergence of artemisinin partial resistance in the WHO African Region is of great global concern. Artemisinin-based combination therapies (ACTs) remain efficacious in countries in this region; thus, there should be no immediate impact for patients.
• In the Greater Mekong subregion (GMS), artemisinin partial resistance is likely to have been involved in the spread of resistance to ACT partner drugs, and there are concerns that the same could happen in the WHO African Region.
• WHO will work with countries to develop a regional plan for a coordinated response to this threat. An immediate priority is to improve therapeutic efficacy and genotypic surveillance, to better map the extent of the resistance.

WHO recommendation on the use of the RTS,S/AS01 malaria vaccine

• In January 2016, WHO recommended further evaluation of RTS,S/AS01 (RTS,S) in a series of pilot implementations, to address several gaps in knowledge before considering wider country-level introduction.
• As part of the Malaria Vaccine Implementation Programme, in January 2016, WHO recommended the RTS,S malaria vaccine for pilot introduction in selected areas of three African countries: Ghana, Kenya and Malawi.
• Data from the pilot introductions have shown that the vaccine has a favourable safety profile; significantly reduces severe, life-threatening malaria; and can be delivered effectively in real-life childhood vaccination settings, even during a pandemic.
• On 6 October 2021, WHO recommended that the RTS,S malaria vaccine be used for the prevention of P. falciparum malaria in children living in regions with moderate to high transmission.

TRENDS IN THE BURDEN OF MALARIA

Malaria cases

• Globally, there were an estimated 241 million malaria cases in 2020 in 85 malaria endemic countries (including the territory of French Guiana), increasing from 227 million in 2019, with most of this increase coming from countries in the WHO African Region. At the Global technical strategy for malaria 2016–2030 (GTS) baseline of 2015, there were 224 million estimated malaria cases.
• The proportion of cases due to Plasmodium vivax reduced from about 8% (18.5 million) in 2000 to 2% (4.5 million) in 2020.
• Malaria case incidence (i.e. cases per 1000 population at risk) reduced from 81 in 2000 to 59 in 2015 and 56 in 2019, before increasing again to 59 in 2020. The increase in 2020 was associated with disruption to services during the COVID-19 pandemic.
• Twenty-nine countries accounted for 96% of malaria cases globally, and six countries – Nigeria (27%), the Democratic Republic of the Congo (12%), Uganda (5%), Mozambique (4%), Angola (3.4%) and Burkina Faso (3.4%) – accounted for about 55% of all cases globally.
• The WHO African Region, with an estimated 228 million cases in 2020, accounted for about 5% of cases.
• Between 2000 and 2019, case incidence in the WHO African Region reduced from 368 to 222 per 1000 population at risk, but increased to 232 in 2020, mainly because of disruptions to services during the COVID-19 pandemic.
• The WHO South-East Asia Region accounted for about 2% of the burden of malaria cases globally. Malaria cases reduced by 78%, from 23 million in 2000 to about 5 million in 2020. Malaria case incidence in this region reduced by 83%, from about 18 cases per 1000 population at risk in 2000 to about three cases in 2020.
• India accounted for 83% of cases in the region. Sri Lanka was certified malaria free in 2016 and remains malaria free.
• Malaria cases in the WHO Eastern Mediterranean Region reduced by 38%, from about 7 million cases in 2000 to about 4 million in 2015. Between 2016 and 2020, cases rose by 33% to 5.7 million.
• Over the period 2000–2020, malaria case incidence in the WHO Eastern Mediterranean Region declined from 21 to 11 cases per 1000 population at risk. The Sudan is the leading contributor to malaria in this region, accounting for about 56% of cases. In 2020, the Islamic Republic of Iran had no indigenous malaria cases for 3 consecutive years.
• The WHO Western Pacific Region had an estimated 1.7 million cases in 2020, a decrease of 39% from the 3 million cases in 2000. Over the same period, malaria case incidence reduced from four to two cases per 1000 population at risk. Papua New Guinea accounted for nearly 86% of all cases in this region in 2020. China was certified malaria free in 2021 and Malaysia had no cases of non-zoonotic malaria for 3 consecutive years.
• In the WHO Region of the Americas, malaria cases reduced by 58% (from 1.5 million to 0.65 million) and case incidence by 67% (from 14 to 5) between 2000 and 2020. The region’s progress in recent years has suffered from the major increase in malaria in the Bolivarian Republic of Venezuela, which had about 35 500 cases in 2000 and more than 467000 cases by 2019. In 2020, cases reduced by more than half compared with 2019, to 232 000, owing to restrictions on movement during the COVID-19 pandemic and a shortage of fuel that affected the mining industry, which is the main contributor to the recent increase in malaria in the country. These restrictions may also have affected access to care, reducing cases reported from health facilities.
• Countries that experienced substantial increases in the region in 2020 compared with 2019 were Haiti, Honduras, Nicaragua, Panama and the Plurinational State of Bolivia.
• The Bolivarian Republic of Venezuela, Brazil and Colombia accounted for more than 77% of all cases in this region.
• Argentina, El Salvador and Paraguay were certified as malaria free in 2019, 2021 and 2018, respectively. Belize reported zero indigenous malaria cases for the second consecutive year.
• Since 2015, the WHO European Region has been free of malaria.

Malaria deaths

• In 2019, WHO updated the distribution of mortality in children aged under 5 years by cause of death (CoD). This affected the malaria CoD fraction, raising the point estimate of malaria mortality from 2000; however, this change has had little effect on trends in malaria mortality.
• Globally, malaria deaths reduced steadily over the period 2000–2019, from 896 000 in 2000 to 562 000 in 2015 and to 558 000 in 2019. In 2020, malaria deaths increased by 12% compared with 2019, to an estimated 627 000; an estimated 47 000 (68%) of the additional 69 000 deaths were due to service disruptions during the COVID-19 pandemic.
• The percentage of total malaria deaths in children aged under 5 years reduced from 87% in 2000 to 77% in 2020.
• Globally, the malaria mortality rate (i.e. deaths per 100 000 population at risk) halved from about 30 in 2000 to 15 in 2015 and then continued to decrease but at a slower rate, falling to 13 in 2019. In 2020, the mortality rate increased again, to 15.
• About 96% of malaria deaths globally were in 29 countries. Six countries – Nigeria (27%), the Democratic Republic of the Congo (12%), Uganda (5%), Mozambique (4%), Angola (3%) and Burkina Faso (3%) – accounted for just over half of all malaria deaths globally in 2020.
• Malaria deaths in the WHO African Region reduced by 36%, from 840 000 in 2000 to 534 000 in 2019, before increasing to 602 000 in 2020. The malaria mortality rate reduced by 63% between 2000 and 2019, from 150 to 56 per 100 000 population at risk, before rising to 62 in 2020.
• Cabo Verde and Sao Tome and Principe have reported zero malaria deaths since 2018.
• In the WHO South-East Asia Region, malaria deaths reduced by 75%, from about 35 000 in 2000 to 9000 in 2020.
• India accounted for about 82% of all malaria deaths in the WHO South-East Asia Region.
• In the WHO Eastern Mediterranean Region, malaria deaths reduced by 39%, from about 13 700 in 2000 to 8300 in 2015, and then increased by 49% between 2016 and 2020, to 12 300 deaths in 2020.
• Most of the increase was observed in the Sudan, where more than 80% of cases are due to P. falciparum, which is associated with a higher case fatality rate than P. vivax cases.
• In the WHO Eastern Mediterranean Region, the malaria mortality rate reduced by 50% between 2000 and 2020, from four to two deaths per 100 000 population at risk.
• In the WHO Western Pacific Region, malaria deaths reduced by 47%, from about 6100 cases in 2000 to 3200 in 2020, and the mortality rate reduced by 55% over the same period, from 0.9 to 0.4 malaria deaths per 100 000 population at risk. Papua New Guinea accounted for more than 93% of malaria deaths in 2020.
• In the WHO Region of the Americas, malaria deaths reduced by 56% (from 909 to 409) and the mortality rate by 66% (from 0.8 to 0.3). Most of the deaths in this region were in adults (77%).

Malaria cases and deaths averted

• Globally, an estimated 1.7 billion malaria cases and 10.6 million malaria deaths were averted in the period 2000–2020.
• Most of the cases (82%) and deaths (95%) averted were in the WHO African Region, followed by the WHO South-East Asia Region (cases 10% and deaths 2%).

MALARIA ELIMINATION AND PREVENTION OF RE-ESTABLISHMENT

• Globally, the number of countries that were malaria endemic in 2000 and that reported fewer than 10 000 malaria cases increased from 26 in 2000 to 47 in 2020.
• In the same period, the number of countries with fewer than 100 indigenous cases increased from six to 26.
• In the period 2010–2020, total malaria cases in the 21 countries that were part of the “eliminating countries for 2020” (E 2020) initiative reduced by 84%.
• The Comoros, Mexico, the Republic of Korea, Nepal, Eswatini and Costa Rica saw a reduction of cases in 2020 compared with 2019, with reductions of 13 053, 262, 129, 54, 6 and 5, respectively.
• The following countries had more cases in 2020 than in 2019: South Africa (1367 additional cases), Botswana (715), Ecuador (131), Suriname (52), Saudi Arabia (45) and Bhutan (20).
• The Islamic Republic of Iran and Malaysia reported zero indigenous malaria cases for the third consecutive year. Timor-Leste reported zero indigenous malaria cases in 2018 and 2019; however, in 2020, three indigenous cases were reported following a malaria outbreak in the country.
• Azerbaijan and Tajikistan have officially made a formal request for malaria free certification.
• Building on the achievements of the E-2020 initiative, the new E-2025 initiative was launched, identifying a set of 25 countries with the potential to halt malaria transmission by 2025. All E-2020 countries that have not yet requested malaria free certification by WHO have automatically been selected to participate in the E-2025 initiative, along with eight additional countries: the
• Democratic People’s Republic of Korea, the Dominican Republic, Guatemala, Honduras, Panama, Sao Tome and Principe, Thailand and Vanuatu.
• Between 2000 and 2020, in the six countries of the GMS – Cambodia, China (Yunnan Province), the
• Lao People’s Democratic Republic, Myanmar, Thailand and Viet Nam – P. falciparum indigenous malaria cases fell by 93%, while all malaria indigenous cases fell by 78%. Of the 82 595 indigenous malaria cases reported in 2020, 19 386 were P. falciparum cases.
• The rate of decline has been fastest since 2012, when the Mekong Malaria Elimination programme was launched. During this period, indigenous malaria cases reduced by 88%, while indigenous
• P. falciparum cases reduced by 95%.
• Overall, Myanmar (71%) and Cambodia (19%) accounted for most of the P. falciparum indigenous malaria cases in the GMS.
• This accelerated decrease in P. falciparum is especially critical because of increasing drug resistance; in the GMS, P. falciparum parasites have developed partial resistance to artemisinin, the core compound of the best available antimalarial drugs.
• Between 2000 and 2020, malaria transmission has not been re-established in any country that was certified malaria free.

Recommended readings

• National Malaria Laboratory Plan (2020-2025) and Malaria Laboratory Manual-2021
• National Malaria Treatment Protocol 2019, Nepal – EDCD
• National Malaria Surveillance Guidelines 2019, Nepal
• Epidemiological Trend of Malaria in Nepal (2012/13-2017/18)
• Malaria Micro Stratification Report 2018
• Malaria Risk Areas Micro-stratification 2020
• From 30 million cases to zero: China is certified malaria-free by WHO
• Interim Guideline for Malaria Program During COVID-19 in Nepal (Updated)
• WHO launches effort to stamp out malaria in 25 more countries by 2025
• World Malaria Day 2021: Reaching the zero malaria target
• El Salvador certified as malaria-free by WHO
• WHO Guidelines for Malaria (Consolidated Guidelines for Malaria)
• World Malaria Report 2020
• World Malaria Day 2020: “Zero malaria starts with me”
• WHO recommends groundbreaking malaria vaccine for children at risk
• National Malaria Laboratory Plan (2020-2025) and Malaria Laboratory Manual-2021
• Self-audit of the National Malaria Program using the Malaria Elimination Audit Tool