NAIROBI — The government of Burundi has reported millions of cases of malaria this year, grabbing headlines as the United Nations Office for the Coordination of Humanitarian Affairs declared the outbreak had reached “epidemic proportions” by May.
But so far, the government has held back from declaring an epidemic — a move that could increase international resources and alter strategies for the response.
An epidemic declaration can be politically sensitive in terms of how it can impact the nation’s economy and international opinions of how an outbreak has been managed. There is speculation that the government might have its eyes set on next year’s election.
But there is also doubt over the malaria numbers themselves and the explosion of cases, according to Dr. Walter Kazadi Mulombo, the World Health Organization’s representative in Burundi.
In June, Burundi’s Ministry of Public Health announced that the country had recorded 5 million cases of malaria in the first six months of the year, in a country of more than 10 million people. Some 1,800 malaria-related deaths were also reported.
“While we don’t have evidence, I suspect that climate change is playing a role [in the spread of malaria].”— Dr. Walter Kazadi Mulombo,WHO representative in Burundi
If correct, this would be a 97% increase compared to the same period last year. Since June, the government hasn’t released an overall figure for new cases but it has given snapshots of the rising numbers. For example, during the week ending Aug. 25, there were 109,386 cases reported, including 66 deaths.
In September 2018, the Burundi government demanded an ethnic breakdown of local staff from all international organizations in the country. The request is indicative of an emerging trend, where "assertive authorities" seek to influence how humanitarian operations function.
The threshold to declare a malaria epidemic is based on the average number of new confirmed cases over the past three to five years. If the current year has more than double that number, and the data is reliable, then the threshold has been reached.
To better understand the situation in Burundi, WHO has deployed a group of experts to gather evidence and advise the government on next steps. It expects the mission to present conclusions in the next few weeks.
Why could there be a surge of cases?
Massive malaria outbreaks are not uncommon in Burundi, a country that has experienced widespread insecurity, human rights violations, and displacement of its populations since election violence in 2015 when President Pierre Nkurunziza decided to run for a controversial third term.
In March 2017, the government declared a malaria epidemic after 1.9 million cases were reported, with 869 deaths — much lower than the numbers currently being reported. A similar independent evaluation by WHO helped to advise the government on the decision to declare an epidemic at the time. It “paved the way to rapid mobilization of resources and response of the international community,” Kazadi Mulombo said.
A number of factors could have contributed to high numbers again this year, medical experts told Devex, including prolonged rainy seasons.
“While we don’t have evidence, I suspect that climate change is playing a role,” Kazadi Mulombo said. “Now we are seeing rains during the dry season. This expands the malaria transmission season.”
Burundi is not alone in this — neighboring countries have also seen a rise in cases.
The expansion of economic projects such as rice fields is thought to have contributed by increasing the number of stagnant water spots across the country where mosquitoes breed, Kazadi Mulombo added.
In Burundi, there is also a lack of insecticide-treated mosquito nets, said Dr. Martine Nkurikiye, head of the community health department at the Burundi Red Cross. The national government hasn’t distributed bed nets for several years, leaving people with nets that are worn out and no longer usable. These nets are not commonly available in markets, and when they can be found, they are prohibitively expensive for many, she said.
Suspected inefficiency of the first-line drug artesunate-amodiaquine, which is given free in health centers, is also considered a potential factor, she said. The drugs are sometimes shared without a doctor’s prescription. “Suddenly, a person has taken a medication not prescribed by the doctor or takes an incomplete dose,” she said.
Both resistance and improper usage could lead to ineffectiveness, although resistance to this drug has not yet been confirmed in Burundi, Kazadi Mulombo said.
“They [WHO] are not quite sure of the numbers being reported. They want an actual confirmation that it’s a malaria epidemic.”— Dr. Walter Kazadi Mulombo,WHO representative in Burundi
WHO analyzes cases
WHO started receiving information about an increase in malaria cases in Burundi in January, but at that time the surge in the disease was only present in a couple of districts. It has now spread across the country.
A new requirement to share staff ethnicity data with authorities has left international NGOs in Burundi with a difficult decision. While some are complying, others have closed their doors.
WHO recently deployed a mission of epidemiologists to examine the data on recorded cases, exploring whether it’s possible that single cases might have been calculated multiple times. The team is also examining other indicators, such as whether there have been drug stockouts, abnormal consumption of diagnostic tests, and long queues at health centers.
“At that level of cases, we should have expected some drug stock-outs, and we haven’t seen that as we speak,” Kazadi Mulombo said, although the Red Cross’s Nkurikiye said there had been long queues at treatment centers, prompting the government to deploy mobile clinics to help add capacity.
Kazadi Mulombo suspects the government is waiting to decide on whether to declare an epidemic until after the WHO evaluation is completed.
“They are not quite sure of the numbers being reported. They want an actual confirmation that it’s a malaria epidemic,” he said. “There is always this dimension between an outbreak and an epidemic — an epidemic refers to a much larger magnitude, something out of control.”
As in 2017, a declaration could lead to a scale-up in the international response and financing. It could also affect the health sector’s response.
The health community is already intervening to prevent the spread of the disease, Kazadi Mulombo said, including bed net distribution, indoor residual spraying in certain districts, and treatment of confirmed cases. There are also orders in the pipeline for more medicine.
“In the case of a confirmed epidemic, we might resort to other case-management strategies, like going into the community to test and treat before people even visit their health centers,” he said.