UNHCR's HIS data were used to derive malaria incidence and mortality estimates for more than one million refugees living in 60 camps in nine countries, the largest analysis of malaria in post-emergency refugee sites. As expected, annual malaria incidence rates varied geographically and over time. Although few comparable data are available, a retrospective mortality survey from 1998 to 2000 in 51 post-emergency camps in Azerbaijan, Ethiopia, Myanmar, Nepal, Tanzania, Thailand and Uganda reported a higher overall incidence of malaria of 48 cases per 1,000 persons per month (range 0-325; approximately 576 cases per 1,000 persons per year) and 78 cases per 1,000 in children younger than five years of age per month (range 0-463; approximately 936 cases per 1,000 children per year) [2
]. The more recent UNHCR HIS data show that malaria remains a significant cause of morbidity and mortality among refugees despite declining transmission rates in many regions of sub-Saharan Africa [6
Progress has been made in reducing the burden of malaria among refugees in some countries. The annual incidence of malaria in children younger than five years of age decreased more than one third in UNHCR sites within Kenya, Tanzania and Uganda between 2006 and 2009, consistent with changes in the burden of malaria in these countries [6
]. In contrast, the annual incidence of malaria in children increased slightly in four countries between 2008 and 2009. Although a short time interval to assess trends in malaria incidence, the largest increases in malaria incidence over the last two years of observation occurred at two sites in Ethiopia. One site, Shimelba, is close to sites in Sudan that also had an increase in malaria incidence between 2008 and 2009. Sudan had the highest malaria mortality rate among refugees younger than five years of age (4.1 deaths per 1000 refugee children) similar to the estimated malaria mortality rate of non-refugee Sudanese children (4.6 deaths per 1,000 children per year) [13
Data on malaria control interventions, specifically IPTp and ITN coverage, were not associated with malaria incidence in children younger than five years of age. However, changes in UNHCR's policies since 2006 likely contributed to declines in malaria incidence among refugees. Providing LLITNs has been one of UNHCR's primary prevention strategies. At a cost of $5 per net, UNHCR has spent approximately $10,000,000 between 2005 and 2008 on LLITN procurement. In accordance with the Malaria Strategic Plan 2008-12, UNHCR aims to increase LLITN coverage of vulnerable groups in emergency situations to full coverage in stable settings and, with support from the UN Foundation's Nothing But Nets Campaign, provide one net for every 2 persons to sleep under (3-4 nets per household) in 17 African countries most affected by malaria.
Monitoring LLITN use may further improve malaria control. The monitoring of LLITN distribution at sites near Dadaab, northeast Kenya serves as a model program. LLITN distribution targeted 80,000 people in 2009, including pregnant women, children under the age of five years old, hospitals, chronically ill, and the elderly. Community leaders identified recipients and routine distribution occurred at clinics and hospitals. LLITN ownership was monitored through 2010, nested within nutrition surveys. Further quantitative and qualitative studies were conducted to identify net coverage, condition, maintenance practices, factors that affect usage and net preference. LLITN coverage increased from approximately 60% to 86%. Incorporating data on LLITN coverage and use within nutrition surveys can provide important information for targeted interventions in protracted refugee settings.
The use of RDTs for case diagnosis was implemented in many refugee camps but HIS data indicated that only 43% of malaria cases were confirmed. Thus, while diagnostics were available at most UNHCR sites, high coverage was not achieved during the study period. UNHCR subsequently developed standard operating procedures for confirmation of malaria and is working to achieve high coverage of RDT use in malaria endemic areas.
Since 2008, ACT has been available in malaria-endemic countries in Africa and has reached near universal coverage in UNHCR camps, consistent with WHO recommended malaria treatment guidelines [14
]. Shortages of ACT were experienced at camps in Cameroon, Cote d'Ivoire, Kenya, Tanzania, Uganda, and Zimbabwe during the study period, but UNHCR worked closely with the Novartis Foundation to provide drugs to those countries experiencing procurement and distribution challenges.
Including refugees and IDPs in national strategic plans for malaria can decrease morbidity and mortality among displaced persons. In a review of 15 national strategic plans from countries in Africa that host ≥10,000 refugees, only three made specific reference to refugees and five made broad mention of refugees without discussion of specific activities [15
]. Governments that signed the 1951 Convention relating to the Status of Refugees have a legal obligation to assist refuges, including the provision of health care. Furthermore, extending malaria control interventions to refugees will be critical to achieving malaria control and elimination within countries with large populations of refugees.
Several limitations in HIS data collection may have biased these findings. Data were aggregated over the two-year period from January 2008 to December 2009 and averaged to determine a mean annual rate. These average annual rates mask differences in malaria incidence, morbidity and mortality between 2008 and 2009. We aggregated camp-level data by countries but heterogeneities in malaria transmission and control exist within countries. Case definitions, reporting practices, and reporting quality varied at the camp and country levels. Perhaps most importantly, accurate diagnosis of malaria and attributing malaria as the cause of death are prone to misclassification. However, given that similar methods were used over the study period, the interpretation of trends should be valid.