public health malaria control in afghanistan: progress … peshawar, pakistan (jkolaczinski, k...

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Published online February 1, 2005http://image.thelancet.com/extras/04art2383web.pdf

Disease Control and VectorBiology Unit, London School ofHygiene and Tropical Medicine,London, UK (J Kolaczinski PhD, K Graham MSc, S Brooker,M Rowland PhD); HealthNetInternational, 11-A CircularLane, PO Box 889, UniversityTown, Peshawar, Pakistan(J Kolaczinski, K Graham); andDepartment of Health Care andPromotion, Ministry of Health,Kabul, Afghanistan(A Fahim MD)

Correspondence to: Dr Jan Kolaczinski, DiseaseControl and Vector Biology Unit,London School of Hygiene andTropical Medicine, Keppel Street,London WC1E 7HT, [email protected]

www.thelancet.com Published online February 1, 2005 http://image.thelancet.com/extras/04art2383web.pdf 1

IntroductionAfter 23 years of war and political instability, the fall ofthe Taliban regime in 2001 and the subsequent influx ofinternational assistance have resulted in heighteneddevelopment activities in Afghanistan (panel). The firstpriorities in the health sector were to assess the healthinfrastructure, restructure the central Ministry ofHealth, develop a basic package of services, and designan interim health strategy. These tasks have now beencompleted and the basic infrastructure and systemsneeded for further planning of public-healthinterventions are in place. One of the next tasksproposed by leading health-sector donors and theMinistry of Health is the integration of Afghanistan’sformerly vertical malaria control programme into thehealth system. Historically the programme has beenguided by operational research, which has providedessential information for effective implementation ofmalaria control interventions during the eradicationand post-eradication eras. Revival of operationalresearch in the more secure areas of Afghanistanduring the complex emergency (eg, eastern andsouthern regions) in the 1990s allowed for continuationof malaria control and, as necessary, the adaptation ofexisting interventions and development of new onesappropriate to the hostile or unstable circumstances.Such research is possible during lengthy chronicconflicts, especially in areas outside the war zone.Unlike most countries emerging from complexemergencies, Afghanistan now has an evidence base formalaria control. This evidence base can be used to guidethe development of a national strategy with the latestand most appropriate control interventions adapted tothe local culture. The country’s cultural, topographical,and climatic features provide a unique backdrop againstwhich strategic planning activities are happening.Gaining access to remote rural populations is achallenge; many people live in mountain valleys and areunreachable for months during the winter, and strongIslamic beliefs make it hard to reach much of thefemale population. In response to calls for a broader

evidence base for delivery of humanitarian aid,1 wereview the development of Afghanistan’s evidence basefor malaria control and identify new challengesassociated with this transition. We aim to show thefeasibility and benefit of evidence-based humanitarianhealth interventions even in the most complexenvironments.

Malaria in AfghanistanMalaria is endemic in large areas of Afghanistan below2000 metres above sea-level and is highly prevalent inriver valleys used for growing rice. In 2002, the totalmalaria burden was estimated by the WHO to be3 million cases per year.2 With a population of22·5 million (80% of whom live in rural areas) and arecorded annual incidence of 240 episodes per 1000people in the more endemic rice-growing areas aroundJalalabad,3 3 million cases would be the upper estimate.Before the war, in the 1970s, the number of recordedcases of malaria per year varied between 40 000 and80 000 (API, annual parasite index, of 2·5 to 5 per 1000people).4 After 1980, the war caused a progressivebreakdown in all malaria control activities.Environmental deterioration, breakdown of irrigationsystems, population displacement, insecurity andinaccessibility, emigration of health staff, and health

Malaria control in Afghanistan: progress and challenges Jan Kolaczinski, Kate Graham, Abdullah Fahim, Simon Brooker, Mark Rowland

From the 1950s until 1979 malaria control in Afghanistan was implemented through a vertical programme managed

by the government, but little of the original programme remained functional by the early 1990s. Delivery of basic

health care including malaria diagnosis and treatment was done by non-governmental organisations (NGOs) and

UN agencies, which organised cross-border operations from Pakistan and Iran and placed much less emphasis on

vertical programming. From 1992 the situation in the east of Afghanistan became stable enough to allow the

establishment of a network of NGO-supported clinics and to introduce standardised training and monitoring of

microscopists and clinical staff, coordinated by a lead agency specialising in malaria. After the collapse of the Taliban

in 2001 and the subsequent establishment of an interim government, the first steps in health-system rehabilitation

have been taken. The gradual integration of malaria control into routine health-care delivery is planned. This process

should be guided by the knowledge and experience gained during the complex emergency and a focus on malaria

should be maintained until the disease is brought under control.

Panel: Important dates

1948 First malaria control organisation established1949–50 Pilot interventions of DDT indoor residual spraying1952 Organisation of nationwide antimalaria spraying campaigns1954 Afghan Malaria Institute established1958 Attack phase of global eradication campaign initiated1979 Soviet invasion and start of civil war1980–90 Gradual breakdown of malaria control programme 1989 Withdrawal of Soviet Union from Afghanistan1992 Mujahedin government takes power in Kabul1994 Taliban rise to power (capture of Kandahar)November, 2001 Fall of Taliban regime


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service decline all contributed to the progressive rise inthe recorded malaria burden. By 1987, 429 000 caseswere recorded per year (API between 36 and 100 per1000 people) and although reporting of cases hadbecome irregular, this statistic still represented a five-fold to ten-fold rise in burden as a direct consequence ofwar. Local epidemics were reported from the easternregion. The species ratio also changed: before the warPlasmodium falciparum constituted only 1% of malariacases; in 1996, in eastern Afghanistan, about 20% ofmalaria was attributable to P falciparum and theremainder to P vivax;3 clinical data show a similar ratioin the rest of the country. The cause of this change wasnot war but chloroquine resistance. From the firstdetection of resistance in 1984 in Pakistan and 1989 inAfghanistan, the failure rate of chloroquine-treatedP falciparum malaria has risen to more than 80% ineastern Afghanistan and Pakistan. Inadequately treatedcases swell the parasite reservoir, which leads tooutbreaks in remote or insecure areas where effectivesecond-line drugs are generally not available. Althoughdrug resistance was the cause of the heightenedincidence of P falciparum relative to P vivax, the war wasresponsible for fuelling the burden.5–8 Up to now,

chloroquine remains fully effective against P vivax, andsulphadoxine-pyrimethamine remains effective againstP falciparum. Transmission is seasonal from June toNovember, with negligible transmission occurringbetween December and March (although many vivaxinfections relapse during these months). The season-ality and low prevalence (eg, about 10% in endemicareas) results in a population only partly immune tomalaria, with children and teenagers carrying most ofthe burden.3,9

In common with most post-emergency situations,reliable epidemiological data about the distribution ofmalaria in Afghanistan are either sparse or are basedon localised surveys undertaken in areas with goodhealth-care provision or where malaria was known tobe a problem. This fact affects the quantification ofdisease burden for basic planning. In an effort toovercome this difficulty a collaborative project betweenthe non-governmental organisation (NGO) HealthNetInternational, the Ministry of Health, and the LondonSchool of Hygiene and Tropical Medicine has beenestablished to map the risk of P falciparum and P vivaxcountrywide. Data obtained over several years oflocalised surveys have been mapped with a global

600 kilometres300300 0Suitable environment

P falciparum prevalence (%)

O

India

China

Afghanistan

Pakistan

Iran

TurkmenistanUzbekistan

Tajikistan

O·1–9·9�10Insecure areas

Altitude �1800m

�5km from rivers

Unsuitable environment (too hot)

Figure 1: Provisional map of predicted transmission zone for P falciparum in AfghanistanShown here is the first map, which has been used for planning the surveys. Results of previous P falciparum prevalence surveys are shown and areas consideredsuitable for transmission, with the preliminary indicators of altitude (under 2000 m) and proximity to rivers (within 4 km) shown.


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positioning system. With a geographical informationsystem, these data have been related to environmentalfactors known to affect the ecology of malaria and itsmajor anopheline vectors. Data about these factors arederived from a digital elevation model and remotelysensed satellite estimates of temperature, land cover,and humidity. Analysis of these relations and resultingmodels will predict malaria prevalence for the whole ofAfghanistan. These models will then be validated byindependent data obtained through targeted prevalencesurveys planned for the 2004 and 2005 transmissionseasons (figure 1).

Pre-war malaria control: the centralisedapproach (1940s to 1979)Afghanistan’s first malaria control organisation wasestablished after an epidemiological assessment in1947.10 In 1949, trial interventions of dichlorodiphenyl-trichloroethane (DDT) indoor residual spraying wereimplemented with technical support from WHO. Aftersuccessful completion of the trials, nationwide sprayingcampaigns were organised.9,11–13 By 1954, more than1·2 million people were protected by an annual roundof DDT indoor residual spraying (rural areas) orantilarval measures (urban areas), and in 1956 malariaeradication was the goal. The initial effects of themalaria control programme were impressive, withpreviously uninhabited areas in the north being openedup for agricultural development. In 1968, 7·9 millionpeople were covered by the eradication programme.Some areas of the country had entered the consolidationphase. In 1970, a change in the vector situation becameapparent: the original main vector Anopheles superpictushad been almost eradicated but replaced by A stephensiand A culicifacies, which had become resistant to DDTin the east and south of Afghanistan, and by the outdoorresting A hyrcanus and A pulcherrimus in theproblematic rice-growing areas in the north of thecountry.14 When DDT had lost its effectiveness, it wasreplaced by malathion. In cities, temephos replaceddiesel oil for larviciding,15 and in rice-growing areaslarvivorous Gambusia fish were introduced byoccupying Soviet forces.16

Malaria control programme activities were directed bythe National Institute for Malaria and Parasitology inKabul, Afghanistan (now Institute of Malaria andParasitic Diseases) with technical support from WHOand commodity support from UNICEF during theeradication era and from UNDP after 1973. Despitesetbacks and constraints their combined effortsremained moderately successful, steadily increasing thelaboratory network to 240 facilities by 1979. Apart frominsecticide resistance the main operational constraintswere the large increase in the number of mosquitobreeding sites resulting from the rise in irrigation forrice cultivation in previously arid areas, and populationmovements, whether traditional (nomadic pastoral) or

industrial (labour). In 1973 the fact that malariaeradication could not be achieved became clear. Afteradvice from a WHO/UNDP review, the governmentreluctantly redefined its strategy and concentrated onsurveillance by increasing the number of diagnosis andtreatment outposts while trying to maintain existingrates of control, with limited amounts of insecticidesupplied by the USSR, Iraq, and the UK.4 Occasionalepidemics arising from insecticide shortages werebrought under control by mobilising teams fromoutposts and by treating fever cases.

Complex emergency (1979–2001)The Soviet invasion of Afghanistan initiated over twodecades of war and civil strife, during which a third ofthe population (estimated in the early 1980s at14–17 million) fled the country, so that whole regionswere abandoned by most of their inhabitants. The publichealth system collapsed, health professionals emigrated,agricultural systems (eg, irrigation) deteriorated, povertyincreased, and life expectancy fell to 46 years.17 Thissituation resulted in rates of malaria increasing fasterthan any other disease in Afghanistan.18 Little of themalaria control programme remained by the early1990s. In the absence of political stability, long-termplanning became impossible. The best that could bedone was to encourage self-reliance and abandon anynotion of vertical programming.

The pre-war policy of indoor residual sprayingcampaigns with DDT could not be resurrected duringthe chronic conflict. Successful indoor residual sprayingneeds good planning, smooth logistics, reliable healthinformation for targeting worst affected areas, andaccurate timing of the campaigns, but none of thesefactors existed. In the more stable environment of theAfghan refugee camps in Pakistan, indoor residualspraying campaigns were possible, and contributed tothe reduction in malaria burden by more than 50%(slide positivity rate reduced from 25% to 10% duringthe 1990s).19 From 1992 the situation in the east ofAfghanistan became sufficiently stable for HealthNetInternational to pilot alternative techniques to addressthe control needs of Afghanistan. Up to that pointHealthNet International had concentrated on malariacontrol in the refugee camps along the Pakistan-Afghanistan border (with delegated authority from theUnited Nations High Commissioner for Refugees[UNHCR]). Originally established by Médecins SansFrontières (Holland) in 1992, HealthNet International’smission was to develop health systems during chronicconflict or post-conflict conditions rather than to deliveremergency health care. Such an aim needs aninnovative approach and operational research to identifythe most appropriate strategies or interventions. Expertconsultants from WHO and UNHCR encouraged thenecessary research on malaria prevention and personalprotection. Studies were initiated in Nangahar province


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and in the Afghan refugee camps. Treatment guidelineswere examined for effectiveness and alternatives tocostly and operationally difficult indoor residualspraying were investigated.

Treatment of vivax malaria in the region iscomplicated by high rates of glucose-6-phosphatedehydrogenase (G6PD) deficiency.20 Radical treatmentwith a 14-day primaquine regimen is not possible whileG6PD testing of malaria patients remains expensive(about US$3 per test). A truncated 5-day primaquineregimen that is safe for all patients with vivax malaria,irrespective of G6PD status, had been used by Pakistan’smalaria control programme. In the 1990s studies were

done by HealthNet International and UNHCR toexamine the efficacy of this treatment protocol. Therelapse rate of patients taking a supervised 5-dayprimaquine course was no different from those ofpatients treated with chloroquine only.21 On the basis ofthis evidence the 5-day primaquine regimen wasabandoned in Pakistan and not introduced inAfghanistan. To combat the rising chloroquine resist-ance of P falciparum, other treatment regimens wereexplored by HealthNet International and the Ministry ofHealth with endorsement and financial support fromthe WHO/UNDP/World Bank Special Programme forResearch and Training in Tropical Diseases.Combinations of the first-line and second-line treat-ments (chloroquine and sulphadoxine-pyrimethamine)with the new and efficient artemisinin derivatives (ie,artemisinin-based combination treatment) wereassessed at the Ministry of Health Malaria ReferenceCentre in Jalalabad, Afghanistan, and in the Pakistanrefugee camps. These studies followed on from thehighly successful introduction of artemisinin-basedcombination treatment in the Karen refugee camps in

Thailand.22 In Afghanistan (figure 2) and Pakistan thecombination of artesunate with sulphadoxine-pyrimethamine achieved 100% parasitological cure andresulted in lower gametocyte carriage rates than didsulphadoxine-pyrimethamine monotherapy, thus poten-tially lowering transmission. After extensive trials,artemisinin-based combination treatment was recom-mended to the Ministry of Health as the most suitablereplacement for the failing chloroquine and has sincebeen recommended by the WHO EasternMediterranean Regional Office for use in the countycluster of Afghanistan, Pakistan, and Iran.

The first new vector-control intervention to beexplored was insecticide-treated nets, which were notcommonly used in Afghanistan and Pakistan.Insecticide-treated nets had been shown to substantiallyreduce the risk of malaria mortality and morbidity intrials in Africa but not in Asia.23 Effectiveness wasestablished in Afghan refugee camps in Pakistan,24 andwas quickly followed by a trial project of insecticide-treated net sales in Afghanistan in 1992–93. This wasthe first insecticide-treated net social marketing projectin Asia and possibly the first in the world. Despite littletradition of mosquito net use, demand was readilycreated by starting sales of insecticide-treated netsacross several provinces and with health educationdelivered through mosques, local newspapers, andradio. The BBC Pashtu Service’s New Home, New Life,a weekly radio drama about life in a post-conflict Afghanvillage, was an especially effective means of gettinghealth messages across to women (as confirmed by post-intervention surveys), who were largely houseboundduring the Mujahedin and Taliban periods (New Home,New Life aims to provide useful information, throughdrama, about everyday subsistence, agriculture, andhealth).

Subsidised sales through NGO clinics and mobilesales teams quickly increased insecticide-treated netcoverage. Assessment of effectiveness in two areas nearJalalabad showed 60% coverage and 59% of users werelikely to contract malaria compared with non-users.25

Protection against P vivax infection took longer tomanifest itself, because of the masking effect of relapsesfrom previous infections.25,26 The intervention wasgradually expanded throughout Afghanistan; more than500 000 family size insecticide-treated nets had beensold in 22 provinces by the end of 2003 covering about1·5 million individuals.

The highly zoophilic nature of the local Asian malariavectors was confirmed27 and families keeping cattle wereproved at substantially higher risk of malaria.28

Application of pyrethroid insecticides to hair and skin ofanimals effectively killed these mosquitoes, whichstimulated interest in a campaign of zooprophylaxiswith insecticide-treated livestock.29 When tried in sixvillages, the method was as effective as house spraying,at only 20% of the cost.30 Additionally, the method was

Figure 2: Afghan women collecting antimalaria medication at dispensary

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well accepted by communities as the insecticide reducedlivestock ectoparasites, in turn increasing milk and meatyield. However, frequent campaigns are needed toachieve and sustain high coverage, which restricts theapplication of this method to epidemic response and tocommunity-based programmes in limited areas untillonger-lasting insecticide formulations are developed.

Supplementary methods of self-protection wereinvestigated for their potential to be scaled-up. Socialsurveys documented the methods that were used byAfghan refugee communities (mainly mosquito coils,fans, and blankets) and entomological studiesinvestigated their effectiveness. Electric fans, pyrethrumcoils, pyrethroid vaporising mats, and curtains treatedwith permethrin all reduced the entry of mosquitoesinto experimental huts. All methods also reduced bloodfeeding, and treated curtains were most effective.31 Asmost people sleep outside during the hot summer, thesemethods might not be fully effective until the last2 months of the P falciparum transmission season. Thenthey become a useful alternative to insecticide-treatednets, which people stop using when the climate getscooler and they sleep indoors. On the basis of theencouraging results for treated curtains, healtheducation messages accompanying insecticide-treatednet sales were modified to encourage the use of thesenets as curtains and door hangings when familiesstopped using them outdoors.

Mosquito repellents can protect people during theearly evening before they get under the net. Afghanswere the first user group in which it was conclusivelyshown that regular use of skin repellent (DEET) protectsagainst falciparum malaria.32 An effectiveness trial ofskin repellents and insecticide-treated nets showed thatwhen used together they can give full protection frommalaria.33 However, insecticide-treated nets are the morecost-effective solution.34 Social surveys also showed thatmost Afghan refugees protect themselves frommosquito bites when sleeping by using their veil or wrap(known as a chaddar) as a top-sheet.31 Use ofpermethrin-treated chaddars and top-sheets for personalprotection or epidemic control was investigated in twohousehold randomised trials. Compared withpermethrin-treated mosquito nets, treated chaddarsprovided almost the same protection from malaria(permethrin is highly repellent to biting insects)35 andthe methods were equally effective againstanthroponotic cutaneous leishmaniasis.36 Treated sheetsare used as an outbreak response, because they are cost-effective to apply and use already-owned materials(unlike nets, which have to be imported and their usemight need behaviour change). Until the fall of theTaliban, fighting and resource constraints meant thatimplementation of each of these interventions wasrestricted to the southern and eastern regions(Kandahar and Jalalabad), districts around the northerncity of Mazar-e-Sharif, and the city of Kabul.

The challenges of malaria control post-emergencyNational reconciliation and the development of the newpublic-health system presented the first opportunity inmore than 20 years to expand implementation of malariacontrol to all endemic provinces. By contrast with the pre-war era, many components of malaria control will needto be integrated into primary health care delivery. Thisprocess faces several challenges: (1) setting up aparticipatory forum to formulate the strategy; (2)deciding which components to include; and (3)establishing mechanisms that allow cost-effective servicedelivery to populations at risk.

Strategic planning for malaria control was initiallyattempted less than a year after the formation of thetransitional government. In August, 2002, a malaria taskforce was created by NGOs, WHO, and the Institute ofMalaria and Parasitic Diseases. The task force succeededin sharing information and addressing issues ofcoordination, but made no progress towards strategicplanning because: participation was limited to the healthsector; the Ministry of Health was not fully involved(Institute of Malaria and Parasitic Diseasesrepresentatives, although forming part of the Ministry ofHealth, did not have the power to make the appropriatedecisions and were not fully informed of other healthsector developments); and the task force had no legal orclearly endorsed mandate. Maintenance of the forumproved difficult in the transitional environment,characterised by rapid staff turnover, and the malaria taskforce disintegrated after basic decisions related totraining and coordination had been made.

A working group for vector-borne diseases has sincebeen established by the Ministry of Health, to advise thecommunicable diseases section. This group should be

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Figure 3: Insecticide-treated nets are treated in front of customers at a sales outlet


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more effective than the malaria task force, as it ensuresdirect involvement of central Ministry of Health staff,and could thus promote better integration of control ofmalaria with the control of other diseases. Nevertheless,the group has to overcome the limitations of itspredecessor. Participation needs to be broadened andshould incorporate agricultural and private sectors toaddress larval control measures and sustainedinsecticide-treated net coverage,37 respectively. Theworking group will need clear objectives, allowingparticipants to monitor progress. With a forum forstrategy development in place, more information isneeded about how best to deliver and apply the newlydeveloped control tools in the present and future healthsystem. Continuing operational research is needed toinvestigate and adapt the mechanisms and test how toscale-up prevention, diagnosis, and treatment.

10 years of successful social marketing of insecticide-treated nets has created demand far larger than thesupplies of NGOs and UN agencies (figure 3). Until now,implementation has been done by a group ofinternational and local NGOs, coordinated by HealthNetInternational, with sales made through district clinicsand by mobile teams of educators and salesmen visitingmore remote areas. By operating through a network ofwell established partners already working within thehealth sector, accountability and control was maintainedat a time of relative anarchy, as was the link betweeninsecticide-treated nets and health. The present systemswill have to adapt and grow in order for provision ofinsecticide-treated nets to be expanded to a national scalewithin more sustainable public-sector and private-sectorservices. A draft strategy has been written to address theinsecticide-treated net shortage, including improvedtargeting of the limited public-sector resources tobiologically and economically vulnerable groups,combined with establishment of a private sector forinsecticide-treated net sales for people who can afford tobuy nets at full price. To identify vulnerable groups,ensuring that subsidies reach them, and create a marketfor nets and insecticide, will need further systems andimplementation research.

Evidence for the effectiveness of the use of larvivorousGambusia fish is scarce, mainly because of the difficultyof implementing the cluster randomised trial that isnecessary to prove an effect.38 Whether to include thislabour-intensive but resource-cheap method in a nationalstrategy should be determined on the basis of evidencefor or against its effectiveness. After the above mentioneddrug studies, WHO recommended artemisinin-basedcombination treatment as the first-line treatment formicroscopically confirmed P falciparum malaria to theAfghan Ministry of Health, who officially endorsed thetreatment in mid-2003. Up to now most health workers(Ministry of Health, national and international NGOs)remain unaware of this change, because theendorsement was not followed up with a well publicised

change in treatment protocol. Although guidelines havebeen developed, their dissemination and training onthem remain pressing needs. Directly related areoperational research issues of how to differentiate cost-effectively between plasmodium parasites (microscopy orrapid-tests), which method to use when and where (eg,rapid-tests could be used during epidemics), and how tocure the large proportion of patients with vivax malaria inthe presence of a high G6PD deficiency rate. Thechallenge is no longer how to treat P falciparumeffectively but how to pay for the treatment, since itremains unclear who will pay for artemisinin-basedcombination treatment.

Integrating efficient case management and diagnosisof malaria into the general health services is possible andessential. Whether malaria prevention and epidemiccontrol would be well served by integration isquestionable. Malaria in central and south Asiancountries is complex, focal in distribution, and showsnotable temporal and spatial variation. Malaria controlneeds technical knowledge and experience. A countrythat abandons all verticality or fails to establish atechnical core of experts needed to address issues oftraining, epidemiological stratification, surveillance, andresearch, and to match resources or interventionsaccording to geographic or environmental needs, will notcontrol malaria adequately.

The major obstacle to scaling up the basic package ofhealth care is the continuing insecurity in many areas ofAfghanistan. Whether security will improve now thenational elections have been held (October, 2004), orwhether the electoral outcome will only precipitate furtherinstability is unpredictable. Even with improved security,progress towards a national programme of malariacontrol will happen only gradually, and so far even thosedonors (such as the European Commission) who havesupported malaria control over the past decade are notmaking the necessary long-term commitment. Althoughemphasising malaria when there are so many otherimportant health needs in Afghanistan might seempartisan, the creation or maintenance of a structure that isable to focus on malaria until it is largely controlledshould be high on the agenda. Only when that is achievedis it sensible to consider winding down or fully integratingmalaria management into the general health services.

Contributors J Kolaczinski had the idea for the review and prepared drafts; A Fahimprovided background on health sector developments over the pastdecades and on plans for disease control interventions from theperspective of the Afghan Ministry of Health; K Graham and M Rowland made suggestions on structure and content, contributed onhistory and future strategy, epidemiology and new instruments, andhelped critically revise the manuscript; and S Brooker developed the map.

Conflict of interest statementWe declare that we have no conflict of interest.

AcknowledgmentsWe thank Chris Whitty for his constructive criticism of the draftmanuscript. HealthNet International’s malaria control programme is


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supported by the European Commission and the malaria risk mappingstudy was funded by the European Commission Humanitarian Office.MR is supported by the Gates Malaria Partnership and the Departmentfor International Development. S Brooker is supported by the WellcomeTrust. These sources of funding had no role in the preparation of thismanuscript.

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