The Southwestern Kwango Province is outlined in red.
Image credits: Google Maps
The health ministry of the Democratic Republic of Congo (DRC) has confirmed that a mysterious illness in the southwestern Kwango province is a severe form of malaria, with 143 deaths reported so far. The outbreak, which began in late October in the Panzi health zone, has affected 592 people, with a case-fatality rate of 6.2%. Initial symptoms of the disease included fever, headache, cough, breathing difficulties, and weakness, prompting local authorities to notify health officials.1
Reports from December 10 confirmed that, of 12 initial samples, 10 tested positive for malaria. However, WHO Director-General Dr. Tedros Adhanom Ghebreyesus suggested that multiple infections may be involved, particularly given the area’s high rates of malnutrition and low vaccination coverage, which leave the population vulnerable to diseases such as malaria, pneumonia, and measles.2
Investigators have faced significant challenges in accessing the remote region due to difficult road conditions and the rainy season, which have hampered communication and the transport of medical supplies. Initial samples sent to the National Institute for Biomedical Research (INRB) in Kinshasa were of poor quality, but further tests, including respiratory samples, confirmed malaria as the primary cause of the outbreak. The health ministry has also highlighted malnutrition as a contributing factor, weakening patients and complicating recovery.1
What is Severe Malaria?
According to the Severe Malaria Observatory, Severe malaria is a life-threatening complication of malaria, primarily caused by the Plasmodium falciparum parasite. It results in complications such as multiple organ failure, metabolic abnormalities, and serious issues like anemia, hypoglycemia, respiratory distress, convulsions, and coma. If untreated, severe malaria can progress rapidly and lead to death within hours or days. Malaria is particularly deadly for young children, especially in malaria-endemic regions like sub-Saharan Africa.3 According to the WHO, Africa accounts for 95% of the 608,000 global malaria deaths each year, with 80% of these fatalities involving children under five.4
When diagnosed early and treated promptly, malaria is preventable and treatable, and patients can fully recover without lasting effects. If left untreated the parasites multiply rapidly in the bloodstream, causing potential long-term damage to organs and tissues, particularly in children during critical stages of development.3
Challenges in Treatment
The primary treatment for severe malaria is injectable artesunate, which is recommended by WHO guidelines. Artesunate is administered intravenously or intramuscularly for at least 24 hours, followed by a three-day course of oral artemisinin-based combination therapy (ACT). The issue here is that treating severe malaria is particularly challenging in rural areas where healthcare infrastructure is limited. In these regions, patients often need to be transported to facilities capable of administering injectable artesunate, a process complicated by long distances, poor road conditions, and financial barriers.3
In addition, some severely ill children may not be able to take oral medications and require rectal artesunate as a pre-referral treatment. This provides crucial stabilization in remote areas until patients can be transferred to medical facilities capable of providing injectable treatments.3
What You Need To Know
The DRC is facing a severe malaria outbreak in Kwango province, with 143 deaths and 592 cases confirmed so far, compounded by malnutrition and poor healthcare access.
Treating severe malaria in rural areas is hindered by limited healthcare infrastructure, requiring injectable artesunate and pre-referral treatments like rectal artesunate for stabilization.
A study in Uganda reveals concerns about artemisinin resistance in children with severe malaria, highlighting the need for further research and potential changes in treatment guidelines.
The Need for Access and Innovation
Improving access to treatment and diagnostics remains a critical issue in malaria-endemic areas. Efforts to develop new treatments, such as cipargamin, and enhance access to existing therapies are ongoing. Programs like the SEMA-ReACT study aim to optimize severe malaria management in regions where injectable artesunate is not available.3
Antibiotic-Resistant Malaria
A recent study based in Uganda has raised concerns about artemisinin resistance in children with severe malaria. Researchers found that 11% of children with complicated malaria showed partial resistance to artemisinin, the primary drug used to treat severe cases. This resistance was linked to a specific mutation in the PfCup13 gene (A675V). In earlier studies, some children took four to five days to clear malaria parasites after treatment with artesunate, which is longer than the expected three days, suggesting the presence of partial resistance.5
The study also revealed that 10% of children experienced treatment failure, with their infections returning despite initial treatments. This suggests that the partner drug, lumefantrine, may not be as effective as initially hoped. These findings underscore the need for further research into artemisinin resistance and recrudescence in children with severe malaria. If confirmed, these results could lead to a reevaluation of current treatment guidelines for severe malaria, particularly in high-risk populations.5
This outbreak in the DRC underscores the challenges of managing severe malaria, particularly in underserved and hard-to-reach areas. Further samples are expected to be collected and tested in the coming days to confirm whether other diseases are also contributing to the outbreak.
References
1. Congo’s health ministry says unknown disease is severe malaria. Reuters. December 17, 2024. Accessed December 18, 2024. https://www.reuters.com/world/africa/congos-health-ministry-says-unknown-disease-is-severe-malaria-2024-12-17/
2. Disease Outbreak News; Undiagnosed disease – Democratic Republic of the Congo. World Health Organization. December 8, 2024. Accessed December 18, 2024.
https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON546
3. Severe Malaria Observatory. Accessed December 18, 2024. https://www.severemalaria.org/
4. WHO. Malaria. December 11, 2024. Accessed December 18, 2024. https://www.who.int/news-room/fact-sheets/detail/malaria
5. Henrici RC, Namazzi R, Lima-Cooper G, et al. Artemisinin partial resistance in Ugandan children with complicated malaria. JAMA. Published online November 14, 2024. Accessed December 18, 2024. doi:10.1001/jama.2024.22343
