Malaria is a major health problem in Ghana where there are between 3 million and 5 million cases diagnosed annually. The country aims to eliminate the disease and implement a strategic plan to be completed until 2015. The objective of this review is to identify the main determinants of health that affect the control and eradication of malaria, the importance of integrated vector control together with the confirmed diagnosis of the disease and the use of biolarvicides as apossible alternative to achieve such elimination. If developed together all the existing interventions in a sustainable manner, its control and the results may be satisfactory. Otherwise, the tendency of the disease will continue to increase, as shown in epidemiological and health spending. It is the main conclusion of this work: the need for a global strategy in conjunction with other health and inter-sectorial actions.
Keywords: malaria, elimination, integrated vector control, determinants of health, biolarvicides.
In 1946, the World Health Organization (WHO) in its Constitution Act states that “health is a status of complete physical, mental and social welfare, not merely the absence of diseases or infirmities”.
The concept has evolved over the years and has had different approaches, proposed by scientists such as Milton Terris, Rene Dubos, Henry Najera, among others, to reach a more complete status, as defined by Luis Salleras “achieving the highest level of physical, mental and social welfare and capacity to operating the social factors that are immersed in the individual and the community” [1-3].
In 1974, Marc Lalonde, former Minister of Health in Canada, published an anthology report that provided a modern framework for analyzing problems and identifying health needs, and choose the means to satisfy them. This framework is based on the division of health in four broad elements: human biology (genetics, aging), environment (physical, chemical, biological and sociocultural), lifestyle (health behaviors) and health care systems .
The WHO estimates are optimistic for the health of humanity in the XXI century: life expectancy will be greater and better quality of life (with less disability and disease). The fight has two simultaneous fronts: infectious diseases and chronic non-communicable diseases (cardiovascular diseases, cancer, diabetes and dementia, mainly) .
However, in 2006 there were, according to its own estimates, around 247 million cases of malaria between 3 300 million people at risk, with almost one million deaths, mostly among children under 5 years. In 2008 there were 109 malaria endemic countries, 45 of them in Africa [6-9].
In the last decade, the prevalence of malaria in Africa increased at an alarming rate, accounted for 2.3 % of global disease and 9 % of the disease on the continent [9,10].
A number of factors seem to contribute to the resurgence of malaria:
1) Rapid spread of resistance of malaria parasites to chloroquine and other quinolones, coupled with physiological resistance of different kinds of mosquitoes to chemical insecticides.
2) Frequent armed conflict and social problems in many countries, forcing large populations to live under difficult conditions in areas of high malaria transmission.
3) Migration within a country with little immune populations to areas where transmission is high.
4) Changing patterns of rainfall and the development of water-related projects such as dams and irrigation schemes, which create new mosquito breeding sites.
5) Adverse socioeconomic conditions that reduce the health budget and lead to a basic inadequacy of funds for drugs.
6) High birth rates and rapid increase in the most vulnerable population (under 5 years).
7) Changes in vector behavior, particularly endophily and exophily .
The WHO, the UN Children’s Fund (UNICEF), the United Nations Development Program (UNDP) and the World Bank launched in 1998 the Roll Back Malaria (RBM) to bring together key stakeholders in the fight against this worldwide scourge. This initiative generated a new political commitment to fight against the disease and money contributions went to another level, but the threshold was very high: to halve the burden of disease and deaths from malaria by 2010.
A premise of RBM is that malaria can not be removed at once, but should and can be controlled .
In September 2000, leaders from 189 countries gathered at the UN headquarters in New York and adopted the Millennium Declaration, an agreement to work together to build a more secure, prosperous and equitable world. The statement resulted in an action plan of eight measurable goals and time limit to be reached by 2015, known as Millennium Development Goals (MDGs):
1. Eradicate extreme poverty and hunger.
2. Achieve universal primary education.
3. Promote gender equality and empowerment of women.
4. Reduce infant mortality.
5. Improve maternal health.
6. Combat HIV and AIDS, malaria and other diseases.
7. Ensure environmental sustainability .
By 2000 it was undeniable that progress in the health sciences and the availability of resources to ensure at all correspond to the actual health of human populations in the world. Discussions were held at the United Nations to mark the new millennium and its objectives or goals, emphasized the social background of the issue of health and pointed to what was called “causes of causes”, namely direct intervention in the “social environment” .
The results in the most graceful cases show that success is possible in most countries, although the MDGs will be achieved only if additional coordinated actions are taken immediately, and if such actions are held until 2015. All parties must comply in its entirety, the commitments agreed in the Millennium Declaration and subsequent statements.
The number of people in extreme poverty in sub-Saharan Africa has leveled off and the poverty rate has fallen by almost 6 % since 2000. However, this region is on track to achieve the goal of cutting poverty in half by 2015 .
There are four stages (figure 1) on the way to the elimination of malaria, so that in July 2008, 109 countries or territories affected by malaria were classified as follows: control (82), pre-elimination (11), elimination (10) and prevention of reintroduction (6) .
The phase transition that WHO proposes depends on the number of positive cases diagnosed as febrile and the ability to reorganize the different stages of the program, related according to the endemicity of malaria in the country where to eliminate or eradicate it .
It follows a process of analysis, implementation, evaluation, investigation of cases, and reduction of prevalence to obtaining zero cases during a period of 3 years .
Malaria control means reducing malaria to a level that does not represent a problem for public health , which is already an important step, though difficult to achieve.
The malaria parasite was discovered by Alphonse Laveran, on November 6, 1880 . Since then there have been more than 100 years and its control or elimination was only possible in countries with stable vector control programs and a high political will based on the health of the population. These programs focused with high financing, mainly on vector control, early diagnosis and active screening of cases where medical coverage and accessibility to health services do not distinguish location, sex, race or social class, and so it is only possible through this way .
According to global health indicators Ghana is one of the 82 countries classified as controlling malaria, because the disease in all ages shows a steady trend over the past 6 years; however, increased in children less than 5 years. On the other hand, mortality in 2007 increased by 61 %, which was among the 10 African countries with the highest number of deaths from this cause.
The overall objective of the National Program for Malaria Control in Ghana under the Strategic Plan for 2015 is to facilitate human development by reducing the disease burden of malaria by 75 %, using as reference the year 2006.
For this the following specific objectives are proposed:
- The 100 % of households should have at least one insecticide treated mosquito net (ITN).
- The 80 % of the general population should sleep under a mosquito net treated with insecticide.
- Increase the number of children and pregnant women sleeping under treated nets.
- The 100 % of pregnant women should receive at least two intermittent preventive treatments with sulfadoxine-pyrimetamine.
- That 90 % of all the internal structures of the selected districts are covered by residual spraying .
The country does not arise as a fundamental objective in the interruption of transmission of malaria, vector control as the main strategy for the integrated control (IVM, Integrated Vector Management), but only as an alternative.
However, vector control is given to integrated approaches because some vectors are responsible for multiple diseases and some interventions are effective against several vectors. The concept of IVM was developed as a result of lessons learned from integrated pest management used in the agricultural sector. IVM aims to optimize and rationalize the use of resources and tools for vector control. The integrated vector management decision-making is a process for managing vector populations, which is done in order to reduce or interrupt vector-borne diseases.
The characteristic features of IVM include:
- Selection of methods based on knowledge of local vector biology, disease transmission and morbidity.
- Use a variety of interventions, often in combination and synergistically.
- Collaboration within the health sector and other public and private sectors that impact on vector breeding and hatcheries.
- Participation committed to local communities and interests.
- A regulatory and legislative public health framework.
- Rational use of insecticides.
- Good management practices.
- An IVM approach takes into account the infrastructure and health resources and integrates all the possible effective measures, whether chemical, biological or environmental. IVM also encourages an integrated approach to disease control [21,22].
In August 2009, the Minister of Health of Ghana expressed its support to eradicate (first of all to eliminate) malaria in the country in a short period of time, and support even to neighboring countries to solve this problem. For this a launch of unification of all organizations involved in fighting the disease was conducted .
The control of malaria is a scientific and technical activity that requires a skilled and dedicated staff with training in epidemiology and entomology, making maps, planning and evaluation of management of the workforce. Staff must be prepared to undertake an arduous fieldwork. They are joined by clinicians and laboratories that play an important role in the confirmatory diagnosis of the disease [24-26], all integrated with ongoing evaluation to enable adjustment of actions and incorporating others if necessary.
There is no doubt that the effectiveness of mosquito control measures and the use of drugs are the most powerful weapons available today to substantially reduce malaria .
In areas where transmission is low, the disease has been eliminated in this way. However, considering the use of the tools currently available, both categories are based primarily on chemical insecticides of entities and therapeutic agents, who are vulnerable to the development of resistance of the mosquito vector and parasite. Alternative medicines and insecticides for malaria are far from being the best option today, which puts the control of malaria in a considerable risk .
Eliminate malaria from many parts of the world where transmission intensity is high will require innovative and effective tools than those used today. The future of global malaria control and elimination will depend, therefore, on the success of research and development of new and more effective tools in its elimination .
In response to this problem, Pharmaceutical Biological Laboratories (LABIOFAM, Cuba) have developed two biological larvicides: Bactivec® and Griselesf®. The active ingredients are the respective specific entomopathogenic bacteria on mosquito larvae, Bacillus thuringiensis, israelensis variant, serotype H-14 and Bacillus sphaericus strain 2362. These bacteria were isolated, first by Goldberg and Margalit 1976 in the Negev Desert, Israel, and then in Nigeria, by Kaduna in 1981.
Biological larvicides Bactivec® and Griselesf® made by LABIOFAM ensure high efficiency in the control of larvae of different species of mosquitoes in urban, rural, industrial and tourism development ecosystem. They also can be used in the most varied climates and conditions of application, and are totally innocuous to other animals and plants found in different aquatic environments, where mosquitoes grow. As these larvicides are very biodegradable, they have a non-invasive behavior in the environment, and can be efficiently integrated with environmental sanitation control programs in man diseases transmitted by mosquitoes. Bactivec® also has proven effective in the fight against sandfly vectors of the neglected tropical disease onchocerciasis. The Bactivec® has been well accepted in different human communities, because of its efficacy, safety and easy application in mini-doses against larvae of the mosquito Aedes aegypti. This has facilitated the application of these products by health technicians, and even by the inhabitants themselves, in their homes or on the periphery of these.
These products have been used effectively in different countries of Latin America, Africa and Asia.
Its use has focused on the successful fight of the vectors aforementioned, both preventively and as a component of integrated vector management programs. They have also been useful in situations of outbreaks of serious diseases like yellow fever, dengue, malaria, human filariasis, various types of encephalitis and onchocerciasis. They are also used in pest control of other species of bloodsucking flies, whose bites cause discomfort to man, both in the community sector and in tourism.
The Bactivec® is used in Cuba since 1980 and Griselesf® was first used in 1990. In Cuba these products have been recognized and awarded by the Cuban Office of Industrial Property and different ministries. Abroad are recognized by public health and agriculture and private companies, and specialized agencies of the United Nations system, such as the Pan American Health Organization (PAHO), WHO and UNDP .
From February 2008 to date, in Accra metropolitan area, with an area of nearly 200 km2 and an estimated 2 551 731 inhabitants in 2010, which represents 57 % of the population in the region, biolarvicides are permanently used in different mosquito breeding. Its use has allowed a significant reduction in malaria morbidity, recognized even by the health authorities of that country.
Then, will Ghana reduce the burden of malaria by 75 % in 2015 with the implementation of these objectives as the most important? Are these the most important objectives in the medium-term to control malaria and then to eliminate it? Does Ghana have the necessary and sufficient resources? On this basis, identify the main existing determinants of health in the country, linked to the control or elimination of malaria, and propose the use of biolarvicides as a national strategy, are the main objectives of this work.
Materials and methods
We conducted a descriptive revision of indicators provided by official sources of health information in the country and Internet (Biostatistics and WHO) CD-ROM, magazines published by the Ministry of Health, official documents, final reports of programs, the local media and country Web sites, in order to assess whether it is really possible to eliminate short-term malaria in Ghana in the framework of health determinants and meeting the objectives set by the National Program for Malaria Control in the country.
Articles included in the review are linked to malaria: concepts, strategies, integrated vector control, diagnosis, treatment, eradication, population characteristics related to the mode and lifestyle, human and material resources, as well as social indicators related to the subject.
Results and discussion
National Program for Malaria Control in Ghana describes in its Strategic Plan for Malaria Control in the period 2008 to 2015, “Ghana has a population estimate for 2008 of more than 22 million inhabitants, 46 % of it is less than 15 years, with annual growth of 2.7 %; therefore, it is expected that the country’s current population will double in 26 years, thus pushing the economy, environment and crowded urban centers”.
On the other hand it states that “development trends are generally positive: the incidence of poverty is 35 % (considering it dropped from 52 % in 1992), life expectancy increased to 57 years, HIV prevalence continues / AIDS in young adults, in a 3 %” and relates that “ these positive trends may be due to the fact that total health spending has been rising over the last decade” .
Other indicators (table 1) highlight that the rate of access to electricity in Ghana is 55 %, the gross rate of educational enrollment increased from 70.7 % in 2002 to 80.1 % in 2004 and is estimated that to reach the target of 85 % coverage in water and sanitation by 2015, it will require that about 1.4 million people a year gain access to safe water and 1.6 million per year to adequate sanitation. To achieve this it must double or triple the funding received annually by Ghana, the country will have to have greater institutional capacity, and must solve the problems of solvency of the utilities, for which tariffs will reach cost recovery levels. Ghana is one of the best countries in Africa after South Africa’s economic performance, yet remains on the 94 place among 175 economies .
These indicators, although considered positive because they have improved, they expose little social development, high poverty, low literacy levels, gender inequality, poor coverage and poor quality of medical services. The information sources are not reliable; they are based on pilot studies conducted in previous years and no update for lack of resources.
Malaria in Ghana, according to statistics from the Ministry of Public Health in 2009, represented 51.5 % of all causes of outpatient visits, more than 6 million cases and a trend towards increase in the last 4 years .
According to WHO the trend of malaria cases in all ages is to decrease. However, due to its high incidence in children under 1 year, malaria in the country is considered hyperendemic  (graphic 1 and 2).
The disease prevalence is high throughout the country, but is accentuated in the north, which is 100 %, so that Ghana is considered a country with high transmission of malaria [35,36].
In intricate areas of difficult access, vector control is unsustainable unless the population itself involves the use of safe products, of broad spectrum and long-term stability in the medium, such as biolarvicides Bactivec® and Griselesf®.
In Human Resources it is reported that the number of doctors has increased from 1 514 in 2006 to 1 676 in 2007. According to population rate there was a doctor per 15 423 inhabitants in 2006 and 1 per 13 683 inhabitants in 2007 . Although the trend is toward open reduction, or greater public access to qualified personnel as the years go by, this is a very unfavorable indicator compared to other countries  (graphic 3).
The situation is critical in some regions, as in the north, where poverty and low cultural level is acute. With the nursing staff is the same. The indicators are a nurse per 1 537 inhabitants in 2006 to 1 per 1 451 in 2007 (graphic 4).
Specialist care in health services is essential for the control of malaria or other diseases, since the accurate diagnosis and early and effective treatment can shorten the duration of the infection and prevent later complications, including the vast majority deaths. Access to treatment should be considered not only a component of malaria control, but a fundamental right of all people at risk .
By elimination of a disease means the reduction of incidence to zero in a defined geographic area as a result of deliberate efforts, requiring continued intervention measures .
On the other hand, the elimination of a disease as a public health problem means to drastically reduce the burden of disease to a level considered acceptable, given the current tools available and the health situation in the region. At this level, neither the prevalence of the disease limits the social productivity or the community development.
Public health strategies applied to eliminate or reduce diseases to acceptable levels go beyond the usual measures of control. To strengthen the efforts against poverty-related diseases, Member States could develop integrated plans under the same framework, while considering the following:
a) Existing global plans, at regional or country level to eliminate or control these diseases.
b) Existing guidelines on selected diseases to support countries in achieving the goals of elimination or control.
c) Existing tools, such as drugs and diagnostic techniques to support surveillance systems.
d) Decisions based on data from research to strengthen health surveillance systems and mapping to identify disease outbreaks and determine other overlapping diseases in geopolitical zones (hotspots) to implement integrated measures.
e) Reducing gaps in neglected diseases “that can be treated in groups” between areas of the region.
f) To ensure that sufficient resources are available to the primary care system to help reducing inequalities in health.
g) Continue interprogramatic interventions that meet the various plans into a comprehensive vision based on the social determinants of each area designated for the intervention (critical zone). Interventions should address the factors and mechanisms through which social conditions affect community health and, where possible, be addressed through social and health policies.
h) Continue community involvement and the forging of partnerships across sectors, to be achieved the cooperation of the community, stakeholders and all stakeholders and potential partners within and outside the health sector to ensure that activities are sustainable.
i) Pursue horizontal cooperation: to identify which countries share problems or borders where selected illnesses occur to promote joint actions and plans between countries.
j) Increased support given by international partners in the fight against neglected diseases and other infections related to poverty .
Global health agencies such as PAHO and WHO, propose as major strategy in controlling malaria, prevention, surveillance, early detection and control of epidemics, integrated vector control, boost diagnosis and appropriate treatment of cases, intensive pharmacovigilance of potential resistance to treatment and application of results to the definition of the standard of care, strengthening primary health care and integration of prevention and control initiatives with other health programs and community participation .
In the specific case of Ghana, several strategies are proposed  (table 2).
Some authors argue that the reason why the intradomicilliary residual spraying never eliminate malaria in sub-Saharan Africa is the genetic predisposition of some mosquitoes bite only outdoors. It cannot be said that someone can not get malaria if is inside a house. That’s absolute nonsense. An infected person can indirectly infect other 100. Consistent with this, authorities are determined to treat the symptoms, not the cause of malaria, which is the mosquito. These experts believe that the 760 million dollars used in malaria control and related problems in the country in 2008 can be used more efficiently in a more comprehensive control and eliminate malaria in Ghana .
Summarizing the aforementioned, within the territory, morbidity and poverty indicators are high, there is shortage of health personnel and poor diagnostic networks, mosquito infestation is high, and the government burden of the disease is also high. Based primarily on donations, authorities have been implementing measures for malaria control in the past 4 years with little success. If biolarvicides are cheaper, effective and less toxic than the products currently used in the country, why not implementing the national use of biolarvicides for vector control?
Addressing the health problems and their determinants, can Ghana eradicate malaria to meet the objectives proposed by the National Program for Malaria Control? The use of established methods currently used by the country, will allow the country to achieve the expected impact in the next 5 years?
To Dr. Pablo Rodriguez Jimenez, 2nd Degree Specialist in Hygiene and Epidemiology, Public Health assistant professor, senior researcher and master in infectious diseases, for his suggestions, provided support and dedication in making the review.
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Figure 1. Phases of the program from control to elimination of malaria.
Anti-malarial mosquito nets impregnated with chemicals, donated to Africa by the US Agency for international Development (USAID). An unhealthy solution for those who breathe these toxic substances.
Cuban collaborators evaluate infestation levels in Ghana.
Table 1. Socio-economic indicators and of general health of Ghana. Source: MOH/Strategic Plan for Malaria Control in Ghana 2008-2015.
Graphic 1. Incidence rate of malaria in Ghana (2000-2008). All ages and children under 5 years. Rates per 1 000 inhabitants.
Graphic 2. Mortality by malaria in Ghana according to all ages and children under 5 years (2000-2008).
Malaria prevaalence model in Ghana.
Graphic 3. Number of doctors by population and years (2001-2007).
Graphic 4. Number of nurses by population and years (2001-2007).