Over the past five years, malaria prevalence has declined dramatically in The Gambia. The findings which appear in the Lancet* raise the possibility of eliminating malaria as a public health problem in parts of Africa.
Serign Ceesay and colleagues in the MRC and National Malaria Control Programme, with other partners, have been investigating the laboratory and ward records from the MRC hospital at Fajara and four other NGO and Gambia Government health facilities. He says ‘ We observed a decline in malaria in all these health facilities. We looked at malaria admissions and deaths, and we saw that these have fallen dramatically. Laboratory data support this too. In the case of Brikama for example, in 1999 50% of slides examined in their laboratories were positive, whereas in 2006 the figure was less than 3%.’

The team also recorded a substantial shift in the average age of children who were admitted to one hospital with malaria after 2004, with far fewer under 5s being admitted after that year. The average age until 2004 was similar to that recorded ten years previously, so the finding of a trend towards older ages of malaria cases was new. A more substantial decrease of malaria admissions in younger children is likely to be largely due to increased use of insecticide treated nets (ITNs), since this intervention is targeted at children under 5, but it may also reflect a situation in which children are taking longer to acquire immunity. Forty nine per cent of under fives in The Gambia are now reported to be sleeping under ITNs, the highest reported coverage in Africa. A number of other interventions were also introduced during this period, including new drug treatment and prevention regimens and these are likely to have contributed to the decline of the disease.

At this point, it is too early to predict whether the encouraging trend will continue this season. Serign Ceesay says ‘We are closely monitoring the situation with our partners at the National Malaria Control Programme, CIAM and DPI. There hasn’t been any further decline so far this season, but we will find out when we analyse the data for September, October and November.’ There has been a lot of rainfall in The Gambia this year and the team will be investigating its possible impact on the data with keen interest.’

Beyond The Gambia
A similar picture may exist in some areas around The Gambia. Serign Ceesay received an ECOWAS fellowship to compare clinical and laboratory data in Senegal and rural Gambia. He says ‘I carefully chose facilities in Thies that have good laboratories with effective quality control and well trained laboratory technicians, and we observed a similar trend there as we observed in the laboratory data in Brikama and at MRC Fajara.’

Towards elimination
The MRC’s Malaria team has expressed cautious optimism that the disease could be eliminated from The Gambia in the coming years. Dr David Conway (Head of MRC The Gambia’s Malaria Programme) says ‘My thinking is that we could work towards effective control and if the decline is sustained within the Senegambia region, we could be looking towards elimination. Clearly, the National Malaria Control Programme will lead this process; CIAM, MRC and the National Health Laboratory Services will also be powerful partners in this fight. His Excellency the President has launched an initiative to eliminate the disease and we will be working together to respond to the President’s call.’

Asked to comment on the decline in malaria in The Gambia, Mr Malang Fofana (Manager of the National Malaria Control Programme) said ‘the NMCP, WHO, Roll Back Malaria initiative, MRC, UNICEF, CRS, CIAM, the Global Fund – with a more concerted effort we can eradicate malaria from The Gambia. The policy of The Gambia Government under the leadership of His Excellency the President, is aimed at eradicating malaria by using all possible effective strategies and interventions including the use of ITNs, prompt and effective treatment using effective drug combinations, intermittent preventive treatment in pregnancy, indoor residual spraying (IRS) and environmental sanitation. Our bilateral partnerships with countries such as Cuba and Taiwan have boosted our efforts enormously in this fight against malaria in The Gambia. Ultimately, eliminating malaria from The Gambia will require sub-regional cooperation between The Gambia, Senegal and Guinea Bissau; the Department of State for Health is in close contact with malaria programme heads in these countries to strengthen surveillance.’

*Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. The Lancet 372:1545-1554. Serign J Ceesay, Climent Casals-Pascal, Jamie Erskine, Samuel E Anya, Nancy O Duah, Anthony J C Fulford, Sanie S S Sesay, Ismaela Abubakar, Samuel Dunyo, Omar Sey, Ayo Palmer, Malang Fofana, Tumani Corrah, Kalifa A Bojang, Hilton C Whittle, Brian M Greenwood, David J Conway
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